DISSOLUTION OF MARRIAGE FORMS

DISSOLUTION OF
MARRIAGE
FORMS
APPROVED BY
The Missouri Supreme Court
July, 2012
Do not file this page with the court.
DISSOLUTION OF MARRIAGE FORMS PACKAGE
Introduction
The Unauthorized Practice of Law
These forms are provided at no cost to you by the Missouri Supreme Court
Committee on Access to Family Courts so that you may have access to the
Missouri Courts. It is a crime for another person to charge you a fee for preparing
these forms for you unless that person is a licensed lawyer. If anyone other than
a lawyer attempts to charge you for preparing these forms, you should notify the
Office of Chief Disciplinary Counsel, 3335 American Avenue, Jefferson City,
Missouri, 65109.
General Information about All Forms
Information that you enter on these forms can be saved on your computer ONLY if
you are using Adobe Acrobat version 8.0 or higher. They can be completed using
the free Adobe Reader, but you will not be able to save the information you enter.
The forms listed below are interactive. You can enter the information on
these forms before you print them. If you fill the forms in on your computer, much
of the information you enter on one form is automatically transferred to other
forms. For example, if you type your first name on the “Petition for Dissolution of
Marriage,” your first name will also appear on the other forms.
Some forms refer to the husband and wife as the parties, while other forms
refer to the parties as the Petitioner and the Respondent. The Parenting Plan
refers to the Mother and Father. It is assumed that you are the petitioner, or the
person filing the case. Because of this, you must indicate whether you are the
Husband or the Wife so that information from one form can be automatically
transferred to the other forms.
This package also contains bookmarks. These bookmarks help you to
navigate throughout these forms. In addition, there are “links” embedded in the
forms. These links are usually green, and can take you to a related location in the
forms.
If your spouse signs the “Answer” so that service of process is not required,
then you only have to file one copy of the “Petition for Dissolution of Marriage”,
“Statement of Income and Expenses”, “Statement of Property and Debt and
Proposed Separation Agreement”, and “Parenting Plan”. If your spouse does not
sign an “Answer”, then you must file one additional copy of all of these forms.
You should also keep a copy of these forms for your records.
Some additional forms may be required by some Missouri Courts. You should
check with your local court.
Do not file this page with the court.
TABLE OF CONTENTS
1. Petition for Dissolution of Marriage (Form CAFC001)
This is the first form you should complete. Information that you enter on this form
will be transferred to all the other forms in the package.
2. Certificate of Dissolution of Marriage (Form CAFC065)
Most courts require that you file two copies of the Certificate of Dissolution of
Marriage.
3. Statement of Income and Expenses (Form CAFC050)
This form requires that you list income and expenses for both you and your
spouse. A lawyer can assist you in finding out this information.
4. Statement of Property and Debt and Proposed Separation Agreement
(Form CAFC040)
READ THE INSTRUCTIONS ON THIS FORM CAREFULLY.
If both you and your spouse agree on the disposition of property and debt and
on all issues concerning maintenance, you may both sign this form. This
“Separation Agreement” can then be introduced into evidence at your hearing.
5. Respondent’s Answer to Petitioner’s Petition for Dissolution of
Marriage (Form CAFC010)
Your spouse may sign this form if he or she does not want to be personally
served. By signing this form, your spouse is allowing the court to decide your
case. Your spouse may also use this form to disagree with your statements on
your forms.
6. Judgment of Dissolution of Marriage (Form CAFC070)
This is a “proposed” judgment. Different courts handle the preparation of the
judgment in different ways. In some courts, the judge will direct you to prepare a
judgment, and in other courts, the judge will prepare the judgment.
7. Filing Information Sheet (Form CAFC067)
This form is required by most courts to enter the information about your case into
the Court’s computer system.
8. Parenting Plan (Form CAFC501)
This form is only required if there are unemancipated children of this marriage. If
there are no unemancipated children of this marriage, then you do not have to
print this form, nor do you have to file this form.
There are two parts to this form, Part A and Part B. Part A deals with custody
issues of the children, and Part B deals with support issues of the children. You
must complete both parts of the Parenting Plan.
If you have different custody or support arrangements for some of the
children, you must complete a separate Parenting Plan for each set of children.
Do not file this page with the court.
Table of Contents
Print Petition
Clear All Forms
IN THE CIRCUIT COURT OF _________________________, MISSOURI
(County where court is located)
In re the Marriage of
_________________
_____________
____________________
(First)
(Middle)
(Last)
Petitioner, (Your full name should be entered here)
_________
(Jr./Sr./III)
Case No. ____________
(Will be assigned when case is filed)
-andDivision No. ____________
_________________
_____________
____________________
(First)
(Middle)
(Last)
Respondent. (Enter your spouse’s full name here)
_________
(Jr./Sr./III)
(Will be assigned when case is filed)
Petition for Dissolution of Marriage
1. How many petitions have you filed in this case?
This is the first petition I have filed in this case. (Original Petition)
This is the second petition I have filed in this case.
This is the third petition I have filed in this case.
2. Are you the Husband or the Wife?
I am the Wife.
I am the Husband.
3. What is your mailing address?
If you change addresses,
make sure to tell the court
in writing your new
address.
_________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
___________
(Zip)
_________________________
(Telephone Number)
_____________________________
(E-Mail Address)
4. What are the last four numbers of your social security number?
XXX-XX- _____________
5. What is your spouse’s mailing address?
_________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
_________________________
(Telephone Number)
_____________________________
(E-Mail Address)
Throughout this entire case, you will
always be the “Petitioner” and your husband
or wife will always be the “Respondent”.
Your husband or wife is also referred to as
your “spouse”.
This is the address that the court will
use to send information concerning your
case to you.
This address is not necessarily the
same as the address at which you reside.
Even if you do not wish to disclose the
address at which you reside, you MUST still
provide the court with a mailing address.
The last four digits of your social
security number are required by §452.312,
RSM0.
This is the address that the court will
use to send information concerning your
case to your spouse. If you do not know
your spouse’s current address, you should
enter the last known address of your
husband or wife.
___________
(Zip)
6. What are the last four numbers of your spouse’s social security
number?
XXX-XX- _____________
The last four digits of your spouse’s
social security number are required by
§452.312, RSMo. Do not leave this field
blank. If you do not know your spouse’s
social security number, enter “Unknown” in
this field.
Petition for Dissolution of Marriage – Page 1 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
ONE and only ONE box
should be checked on
this page.
7. DIRECTIONS FOR SERVICE ON RESPONDENT
How will your spouse receive legal notice of this proceeding?
Before your case can proceed, your
spouse must be given notice that you have
filed this case. This notice can be given in
one of the methods described on this page.
Respondent has signed a verified “Answer to Petition for
Dissolution of Marriage” which is being filed with the “Petition for
Dissolution of Marriage.” Therefore, do not issue a summons.
If you check this box, you must file the
“Answer to Petition for Dissolution of
Marriage” at the same time you file this
petition. The “Answer” must be signed by
your spouse in front of a notary public.
Respondent has signed a verified “Waiver of Service and Entry of
Appearance” which is being filed with the “Petition for Dissolution of
Marriage.” Therefore, do not issue a summons.
If your spouse signs a “Waiver of
Service and Entry of Appearance,” he or she
has 30 days in which to file an answer to the
petition. The “Waiver of Service and Entry
of Appearance” must be signed by your
spouse in front of a notary public.
Respondent will voluntarily enter his/her appearance in this case
and therefore summons should be issued but held in the Sheriff’s
office for this County. If a verified “Waiver of Service and Entry of
Appearance” is not filed within thirty (30) days, this case may be
dismissed without further notice to Petitioner.
Your spouse can either sign an answer
or waiver within 30 days, or your spouse can
pick up a copy of the papers in the sheriff’s
office for this county within 30 days.
If you select this option, the clerk will
issue a summons, which will be “held” in the
sheriff’s office.
Summons should be served upon Respondent at his/her
residence:
Respondent may be served either at
his/her place of employment or at his/her
home. You should check the appropriate
box.
Your spouse must be served within 30
days of the issuance of the summons.
________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
___________
(Zip)
Summons should be served upon Respondent at his/her place of
employment:
_________________________________________
(Employer’s Name - if applicable)
__________________
(Hours of Employment)
IF YOU ARE GOING TO HAVE YOUR
SPOUSE SERVED, YOU MUST FILE
ANOTHER COPY OF ALL YOUR
DOCUMENTS IN THIS CASE TO BE
SERVED ON YOUR SPOUSE.
________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
___________
(Zip)
Respondent cannot be served in Missouri. Therefore, service by
registered mail is requested. A copy of the “Affidavit for Service by
Mail” is attached to this form. See Missouri Supreme Court Rule
54.12(b)
Service by registered mail is only
available if your spouse resides outside the
State of Missouri.
If you have service by mail, you are not
entitled to obtain any kind of money
judgment against your spouse for such
things as child support or maintenance.
The whereabouts of Respondent are unknown and there is no
way of contacting him or her. I have attempted to locate the
Respondent and have been unable to do so. Therefore, service by
publication will be required. A copy of the “Affidavit for Service by
Publication” is attached to this form. Child support, maintenance or
other money judgments will not be allowed against Respondent if
service is by publication. Publication must be made in the county
where this matter is filed in a newspaper of general circulation. See
Missouri Supreme Court Rule 54.12(c).
You can only obtain service by
publication if the whereabouts of your
spouse are unknown and you cannot locate
him or her by making all reasonable
attempts to find out where he or she can be
served.
If you have service by publication, you
are not entitled to obtain any kind of money
judgment against your spouse for such
things as child support or maintenance.
This option should only be utilized as a
last resort.
Other: ______________________________________________
NOTE: Must be authorized by
Supreme Court rule or statute.
Petition for Dissolution of Marriage – Page 2 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
You should enter your age in years on
this line.
8. What is your age? _______________
(Number of Years)
Choose one...
9. In what country do you currently reside? ______________________
(Country)
10. In what state do you currently reside and for what length of
time have your resided in your state of residence?
_________________________
(State of Residence)
______ ______ ______
Years
Months Days
(Length of Residence in this State)
11. In what county do you currently reside and for what length of
time have you resided in your county of residence?
_________________________
(Name of County)
______ ______ ______
Years
Months Days
(Length of Residence in this County)
Read each question carefully. This question
requests the COUNTRY in which you reside.
It does not request the COUNTY in which
you reside.
You should enter state in which you
reside and the length of time you have been
a resident of the State. Missouri law
requires that one party to a dissolution of
marriage proceeding must have been a
resident of the State of Missouri for at least
90 days. If the time is less than four
months, state the number of days you have
resided in the state.
The “City of St. Louis” is considered a
county. If you live in the City of St. Louis,
you should write “St. Louis City” in the blank.
Also you should enter the length of time
you have been a resident of the county.
Not the City
Not the Country
(See Explanation)
12. What is your current employment status?
Employed
Unemployed
Self-employed
13. If you are employed or self-employed, where do you currently
work?
_________________________________________
(Employer’s Name or type of self-employment)
________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
If you are self-employed, enter a brief
description of the type of work you perform
such as “Landscaping” or “Day care” on the
line for the name of your employer. If you
are self-employed, you should also enter the
address information for your selfemployment.
___________
(Zip)
14. What is your total monthly gross income from all sources?
________________________
(Total Monthly Gross Income)
15. Can you support yourself through the combined income from
your employment and income from property that you will receive
in the dissolution?
Yes
No
16. What is your spouse’s age? _______________
(Number of Years)
Enter the total amount of gross income
you earn each month. “Gross income” is the
amount of money a person earns before
anything such as taxes is deducted. For a
more detailed definition of “gross income”
see Supreme Court Form No. 14
This does not include supporting any
minor children.
You should enter your spouse’s age in
years on the line.
Petition for Dissolution of Marriage – Page 3 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
17. In what country does your spouse currently reside?
Choose one...
_________________________
(Country)
18. In what state does your spouse currently reside and for what
length of time has your spouse resided in his or her state of
residence?
_________________________
(State of Residence)
______ ______ ______
Years
Months Days
(Length of Residence in this State)
19. In what county does your spouse currently reside and for what
length of time has your spouse resided in his or her county of
residence?
_________________________
(Name of County)
Not the City
Not the Country
______ ______ ______
Years
Months Days
(Length of Residence in this County)
20. If your spouse does not live in Missouri, did you and your
spouse live together in Missouri during your marriage?
Yes.
No.
Not Applicable. (My spouse currently resides in Missouri)
You should enter state in which your
husband or wife resides and the length of
time your spouse has been a resident of the
State. If the time is less than four months,
state the number of days your spouse has
resided in the state.
If you do not know in which county your
spouse resides and cannot find out this
information from any source such as family,
friends, telephone listings, or the internet,
then you should enter “Unknown”.
Also you should enter the length of time
your spouse has been a resident of the
county. The “City of St. Louis” is considered
a county.
If you and your spouse have never lived
together in the State of Missouri during your
marriage and he or she does not voluntarily
enter his or her appearance in this
proceeding, the court will lack personal
jurisdiction over your spouse. This means
that the court cannot award any money
judgment to you.
It may be better to file this case in the
state where your spouse resides. You
should consult a lawyer for further
information.
21. What is your spouse’s current employment status?
Employed
Unemployed
Self-employed
Unknown
22. If your spouse is employed or self-employed, where does he
or she currently work?
_________________________________________
(Employer’s Name or type of self-employment)
If your spouse is self-employed, enter a
brief description of the type of work he or
she performs, such as “Landscaping” or
“Day care,” on the line for the name of your
employer. If your spouse is self-employed
you should also enter the address
information for his or her self-employment.
________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
___________
(Zip)
23. What is your spouse’s total monthly gross income from all
sources?
________________________
(Total Gross Monthly Income)
Enter the total amount of gross income
your spouse earns each month. “Gross
income” is the amount of money a person
earns before anything such as taxes is
deducted.
If you do not know the exact amount of
gross monthly income for your spouse, you
should enter your best estimate here.
Petition for Dissolution of Marriage – Page 4 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
24. Can your spouse support him or herself through the combined
income from his or her employment and income from property that
he or she will receive in the dissolution?
Yes
No
Unknown
This does not include supporting any
minor children born of the marriage.
25. Is your spouse on active duty in the military?
Yes
No
You must enter
If your spouse is on active duty in the
armed forces of the United States, the
Servicemembers Civil Relief Act (SCRA)
may prevent you from obtaining a
dissolution of marriage without your
spouse’s consent. You should contact a
lawyer about this situation prior to filing this
petition.
a date on this
line.
26. On what date were you married? _____________
(MM/DD/YYYY)
27. In what country, state and county did you get your marriage
license?
Choose one...
_________________________
(Country)
__________________________
(State)
_________________________
(Name of County)
28. On what date did you and your spouse separate?
_____________
(MM/DD/YYYY)
You must enter
a date on this
line.
You must answer this
question.
You should enter the Country, State
and County where you marriage is
registered.
This is not necessarily the same as the
county where you were married.
The City of St. Louis is considered a
county and is the only city in the state of
Missouri that is a county.
The date of separation is not
necessarily the same as the date one party
moved out of the joint residence of the
parties. Under some circumstances, the
parties may be separated and still be
residing in the same residence.
29. Is there any reasonable likelihood that your marriage can be
preserved?
Yes
No
If you answered “Yes”, then the court
will not grant a dissolution of marriage but
may grant a legal separation.
30. Is your marriage irretrievably broken?
Yes
No
If you answered ‘No”, then the court will
not grant a dissolution of marriage but may
grant a legal separation.
31. State any arrangements which you and your spouse have
made for the maintenance of the other party or the custody and
support of any children.
If you have unemancipated children,
please state any arrangements you and your
spouse have concerning the support and
custody of the children.Maintenance is what
used to be called alimony. It refers to an
amount paid by one party to the other party
for his or her support. It is not the same as
child support.
____________________________________________________________________
____________________________________________________________________
32. Is Wife pregnant?
Yes
No
You should answer “Yes” if Wife is
pregnant even if Husband is not the father of
this child.
33. How many living children do you and your spouse have
together that were born after the date of your marriage?
Each one of these children
should be listed in your answers to
Questions 38 through 41.
_________________
(Number of Children)
Do not answer this question “N/A” or
“Not Applicable.” You MUST enter
a number on this line.
Include in this number all living children
born to Wife during this marriage as a result
of sexual intercourse with Husband including
children who are grown. Do not include
deceased children.
Petition for Dissolution of Marriage – Page 5 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
34. How many living children did you and your spouse adopt?
_________________
(Number of Children)
Do not answer this question “N/A” or
“Not Applicable.” You MUST enter
a number on this line.
35. How many living children do you and your spouse have
together that were born before the date of your marriage?
_________________
(Number of Children)
Do not answer this question “N/A” or
“Not Applicable.” You MUST enter a
number on this line.
36. How many living children did Wife have with someone other
than Husband that were born after the date of their marriage? (This
number includes children born since the parties separated)
_________________
(Number of Children)
Do not answer this question “N/A” or
“Not Applicable.” You MUST enter
a number on this line.
Each one of these children
should be listed in your answers to
Questions 38 through 41.
Include in this number all living children
that were (a) born to Wife and subsequently
adopted by Husband; or (b) fathered by
Husband and subsequently adopted by
Wife; or (c) adopted by both parties. Include
in this number children who are grown. Do
not include deceased children.
Each one of these children
should be listed in your answers to
Questions 38 through 41.
Include in this number all living children
born to Wife before this marriage as a result
of sexual intercourse with Husband including
children who are grown. You should attach
a copy of the birth certificate for these
children to your petition. If Husband is not
listed as the father on the birth certificate,
additional information may be required to be
included in your petition.
Each one of these children
should be listed in your answers to
Questions 38 through 41.
Include in this number all living children
born to Wife during this marriage as a result
of sexual intercourse with a man other than
Husband including any children who are
grown. Do not include deceased children.
Information in addition to the information on
this petition will be required before the court
may proceed with your case.
The number in Question 37 is automatically calculated for you as you fill in Questions 33 through 36.
37. Enter the total number of children from lines 33, 34, 35, and 36.
_________________
(Number of Children)
Do not answer this question “N/A” or
“Not Applicable.” You MUST enter
a number on this line.
Each one of these children
should be listed in your answers to
Questions 38 through 41.
Add the numbers you entered on lines
33, 34, 35, and 36 above and enter the total.
NOTE: If line 37 is zero, then you may skip Questions 38 through 49 and go directly to Question
50.
INSTRUCTIONS FOR QUESTIONS 38 THROUGH 41 PERTAINING TO CHILDREN
Questions 38 through 41 each have 10 subparts lettered ‘a’ through ‘j’. These subparts are arranged vertically in two columns on
each page. Each of these two columns represents the information for one child. Question 38 pertains to the first child, Question 39
pertains to the second child, and so on.
If you answered Question 37 with ‘0’, you should skip Questions 38 through 49 and go directly to Question 50.
If you answered Question 37 with ‘1’, you should answer Question 38 for the one child you listed in your answer to
Question 37 and if the child is not emancipated, you should also answer questions 42 through 49 inclusive.
If you answered Question 37 with ‘2’, you should answer Questions 38 and 39 for the two children you listed in your
answer to Question 37. If either of the children is not emancipated, you should also answer questions 42 through 49 inclusive.
If you answered Question 37 with ‘3’, you should answer Questions 38 through 40 for the three children you listed in
your answer to Question 37. If any of the children are not emancipated, you should also answer questions 42 through 49 inclusive.
If you answered Question 37 with ‘4’, you should answer Questions 38 through 41 for the four children you listed in your
answer to Question 37. If any of the children are not emancipated, you should also answer questions 42 through 49 inclusive.
If you answered Question 37 with a number greater than ‘4’, you should answer Questions 38 through 41 for the
four children you listed in your answer to Question 37. Additionally, you should attach additional pages answering all the questions
asked in Question 38 for each child you have in addition to the children you have described in Questions 38 through 41. If any of
the children are not emancipated, you should also answer questions 42 through 49 inclusive.
You must list the children even if they are adults or if they are in someone else’s custody. You
must also list each child that was born after the date of the marriage even if Husband is not the
father of the child.
Petition for Dissolution of Marriage – Page 6 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
QUESTION 38
CHILD ONE
(To be answered if the answer to question 37 is one or more)
38a. What is the full name of this child?
a.
38b. What are the last four numbers of this child’s Social Security Number?
b. XXX-XX-
38c. What is the current address of this child?
c.
38d. What is this child’s age?
d.
38e. Check all of the following boxes that apply:
(To be answered for each child)
This child is married or is on active duty in the military.
This child is self-supporting and the custodial parent has relinquished parental control over this child by express
or implied consent.
This child is over the age of 21, is not insolvent, and is not physically or mentally incapacitated from supporting
himself or herself.
This child is over the age of 18, has not yet reached the age of 21, is not insolvent, is not physically or mentally
incapacitated from supporting himself or herself, and one or more of the following is true:
This child is not currently enrolled in or attending high school or college.
This child graduated from high school, but has not been continuously enrolled in college since October 1
immediately following his or her graduation from high school.
This child graduated from high school and has been continuously enrolled in college since October 1
immediately following his or her graduation from high school, but has failed to complete at least 12 hours
each semester or complete at least 9 hours and work at least 15 hours per week during the same period.
(This provision does not apply to a child who has been diagnosed with a learning disability or whose physical
disability or diagnosed health problem limits the child’s ability to carry sufficient credit hours.)
If the circumstances of the child manifestly dictate, the court may waive the October 1 deadline for enrollment. “College” means any junior college,
community college, college or university at which the child attends classes regularly. As used in this form, “college” also includes any postsecondary
training or schooling for which the student is assessed a fee and attends classes regularly.
If you did not check any of the boxes in Question ‘38e’, you must answer the rest of the
information for this child on this page (parts ‘38f’ through ‘38j’) and you must also answer
questions 42 through 49 for this child. This child IS NOT emancipated and the court must make
orders with respect to custody and support of this child.
If you checked any of the boxes in Question ‘38e’, you do not need to answer the rest of the
information for this child and questions 42 through 49 do not apply to this child. This child IS
emancipated.
38f. With whom has this child primarily resided during the previous 60 days?
38g. Who should have legal custody of this child?
NOTE: Legal custody refers to
who will make the decisions concerning health, education and welfare for this child. §452.375.1(2),
RSMo.
38h. Who should have physical custody of this child?
NOTE: Physical custody
refers to where this child will reside and what time this child spends with each parent. §452.375.1(3),
RSMo.
38i. Who is the father of this child?
If Husband is not the father of this child, you must
state the name of each person who could be the father.
38j. If this child was born prior to the marriage, is Husband listed as the
father on the birth certificate?
f.
g.
Wife
Husband
Joint Husband/Wife
Third Person
h.
Wife
Husband
Joint Husband/Wife
Third Person
i.
j.
Petition for Dissolution of Marriage – Page 7 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Husband
Other (State Name(s))
____________________
Yes
No
Not Applicable
QUESTION 39
CHILD TWO
(To be answered if the answer to question 37 is two or more)
39a. What is the full name of this child?
a.
39b. What are the last four numbers of this child’s Social Security Number?
b. XXX-XX-
39c. What is the current address of this child?
c.
39d. What is this child’s age?
d.
39e. Check all of the following boxes that apply:
(To be answered for each child)
This child is married or is on active duty in the military.
This child is self-supporting and the custodial parent has relinquished parental control over this child by express
or implied consent.
This child is over the age of 21, is not insolvent, and is not physically or mentally incapacitated from supporting
himself or herself.
This child is over the age of 18, has not yet reached the age of 21, is not insolvent, is not physically or mentally
incapacitated from supporting himself or herself, and one or more of the following is true:
This child is not currently enrolled in or attending high school or college.
This child graduated from high school, but has not been continuously enrolled in college since October 1
immediately following his or her graduation from high school.
This child graduated from high school and has been continuously enrolled in college since October 1
immediately following his or her graduation from high school, but has failed to complete at least 12 hours
each semester or complete at least 9 hours and work at least 15 hours per week during the same period.
(This provision does not apply to a child who has been diagnosed with a learning disability or whose physical
disability or diagnosed health problem limits the child’s ability to carry sufficient credit hours.)
If the circumstances of the child manifestly dictate, the court may waive the October 1 deadline for enrollment. “College” means any junior college,
community college, college or university at which the child attends classes regularly. As used in this form, “college” also includes any postsecondary
training or schooling for which the student is assessed a fee and attends classes regularly.
If you did not check any of the boxes in Question ‘39e’, you must answer the rest of the
information for this child on this page (parts ‘39f’ through ‘39j’) and you must also answer
questions 42 through 49 for this child. This child IS NOT emancipated and the court must make
orders with respect to custody and support of this child.
If you checked any of the boxes in Question ‘39e’, you do not need to answer the rest of the
information for this child and questions 42 through 49 do not apply to this child. This child IS
emancipated.
39f. With whom has this child primarily resided during the previous 60 days?
39g. Who should have legal custody of this child?
NOTE: Legal custody refers to
who will make the decisions concerning health, education and welfare for this child. §452.375.1(2),
RSMo.
39h. Who should have physical custody of this child?
NOTE: Physical custody
refers to where this child will reside and what time this child spends with each parent. §452.375.1(3),
RSMo.
39i. Who is the father of this child?
If Husband is not the father of this child, you must
state the name of each person who could be the father.
39j. If this child was born prior to the marriage, is Husband listed as the
father on the birth certificate?
f.
g.
Wife
Husband
Joint Husband/Wife
Third Person
h.
Wife
Husband
Joint Husband/Wife
Third Person
i.
j.
Petition for Dissolution of Marriage – Page 8 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Husband
Other (State Name(s))
____________________
Yes
No
Not Applicable
QUESTION 40
CHILD THREE
(To be answered if the answer to question 37 is three or more)
40a. What is the full name of this child?
a.
40b. What are the last four numbers of this child’s Social Security Number?
b. XXX-XX-
40c. What is the current address of this child?
c.
40d. What is this child’s age?
d.
40e. Check all of the following boxes that apply:
(To be answered for each child)
This child is married or is on active duty in the military.
This child is self-supporting and the custodial parent has relinquished parental control over this child by express
or implied consent.
This child is over the age of 21, is not insolvent, and is not physically or mentally incapacitated from supporting
himself or herself.
This child is over the age of 18, has not yet reached the age of 21, is not insolvent, is not physically or mentally
incapacitated from supporting himself or herself, and one or more of the following is true:
This child is not currently enrolled in or attending high school or college.
This child graduated from high school, but has not been continuously enrolled in college since October 1
immediately following his or her graduation from high school.
This child graduated from high school and has been continuously enrolled in college since October 1
immediately following his or her graduation from high school, but has failed to complete at least 12 hours
each semester or complete at least 9 hours and work at least 15 hours per week during the same period.
(This provision does not apply to a child who has been diagnosed with a learning disability or whose physical
disability or diagnosed health problem limits the child’s ability to carry sufficient credit hours.)
If the circumstances of the child manifestly dictate, the court may waive the October 1 deadline for enrollment. “College” means any junior college,
community college, college or university at which the child attends classes regularly. As used in this form, “college” also includes any postsecondary
training or schooling for which the student is assessed a fee and attends classes regularly.
If you did not check any of the boxes in Question ‘40e’, you must answer the rest of the
information for this child on this page (parts ‘40f’ through ‘40j’) and you must also answer
questions 42 through 49 for this child. This child IS NOT emancipated and the court must make
orders with respect to custody and support of this child.
If you checked any of the boxes in Question ‘40e’, you do not need to answer the rest of the
information for this child and questions 42 through 49 do not apply to this child. This child IS
emancipated.
40f. With whom has this child primarily resided during the previous 60 days?
40g. Who should have legal custody of this child?
NOTE: Legal custody refers to
who will make the decisions concerning health, education and welfare for this child. §452.375.1(2),
RSMo.
40h. Who should have physical custody of this child?
NOTE: Physical custody
refers to where this child will reside and what time this child spends with each parent. §452.375.1(3),
RSMo.
40i. Who is the father of this child?
If Husband is not the father of this child, you must
state the name of each person who could be the father.
40j. If this child was born prior to the marriage, is Husband listed as the
father on the birth certificate?
f.
g.
Wife
Husband
Joint Husband/Wife
Third Person
h.
Wife
Husband
Joint Husband/Wife
Third Person
i.
j.
Petition for Dissolution of Marriage – Page 9 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Husband
Other (State Name(s))
____________________
Yes
No
Not Applicable
QUESTION 41
CHILD FOUR
(To be answered if the answer to question 37 is four or more)
41a. What is the full name of this child?
a.
41b. What are the last four numbers of this child’s Social Security Number?
b. XXX-XX-
41c. What is the current address of this child?
c.
41d. What is this child’s age?
d.
41e. Check all of the following boxes that apply:
(To be answered for each child)
This child is married or is on active duty in the military.
This child is self-supporting and the custodial parent has relinquished parental control over this child by express
or implied consent.
This child is over the age of 21, is not insolvent, and is not physically or mentally incapacitated from supporting
himself or herself.
This child is over the age of 18, has not yet reached the age of 21, is not insolvent, is not physically or mentally
incapacitated from supporting himself or herself, and one or more of the following is true:
This child is not currently enrolled in or attending high school or college.
This child graduated from high school, but has not been continuously enrolled in college since October 1
immediately following his or her graduation from high school.
This child graduated from high school and has been continuously enrolled in college since October 1
immediately following his or her graduation from high school, but has failed to complete at least 12 hours
each semester or complete at least 9 hours and work at least 15 hours per week during the same period.
(This provision does not apply to a child who has been diagnosed with a learning disability or whose physical
disability or diagnosed health problem limits the child’s ability to carry sufficient credit hours.)
If the circumstances of the child manifestly dictate, the court may waive the October 1 deadline for enrollment. “College” means any junior college,
community college, college or university at which the child attends classes regularly. As used in this form, “college” also includes any postsecondary
training or schooling for which the student is assessed a fee and attends classes regularly.
If you did not check any of the boxes in Question ‘41e’, you must answer the rest of the
information for this child on this page (parts ‘41f’ through ‘41j’) and you must also answer
questions 42 through 49 for this child. This child IS NOT emancipated and the court must make
orders with respect to custody and support of this child.
If you checked any of the boxes in Question ‘41e’, you do not need to answer the rest of the
information for this child and questions 42 through 49 do not apply to this child. This child IS
emancipated.
41f. With whom has this child primarily resided during the previous 60 days?
41g. Who should have legal custody of this child?
NOTE: Legal custody refers to
who will make the decisions concerning health, education and welfare for this child. §452.375.1(2),
RSMo.
41h. Who should have physical custody of this child?
NOTE: Physical custody
refers to where this child will reside and what time this child spends with each parent. §452.375.1(3),
RSMo.
41i. Who is the father of this child?
If Husband is not the father of this child, you must
state the name of each person who could be the father.
41j. If this child was born prior to the marriage, is Husband listed as the
father on the birth certificate?
f.
g.
Wife
Husband
Joint Husband/Wife
Third Person
h.
Wife
Husband
Joint Husband/Wife
Third Person
i.
j.
Petition for Dissolution of Marriage – Page 10 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Husband
Other (State Name(s))
____________________
Yes
No
Not Applicable
Additional Information about Unemancipated Children
Questions 42 through 49 below pertain to all unemancipated children listed in your answers to questions 38 through
41. If there are no unemancipated children, you may skip questions 42 through 49 and go directly to question 50 on
page 12 of this Petition. The information on this page is required under the Uniform Child Custody Jurisdiction and
Enforcement Act, §452.700, RSMo et seq., and under §454.501, RSMo.
42. State all addresses at which the unemancipated children have
resided during the past five years and the name of the person or
persons with whom said children resided.
____________________________________________________________________
43. Do you know of anyone other than you or your spouse that
has physical custody of any of the unemancipated children or
claims to have custody or visitation rights with respect to any of
the unemancipated children?
Yes
No
44. Do you have any information of any other custody proceeding
concerning any of the unemancipated children pending in a court
of this or any other state?
Yes
No
45. Have you participated in any other litigation concerning the
custody of any of the unemancipated children in this or any other
state?
Yes
No
46. Have any of the unemancipated children been a victim of
abuse or neglect?
Yes
No
47. If you answered “Yes” to questions 43, 44, 45, or 46 please
explain.
____________________________________________________________________
____________________________________________________________________
48. Have any orders pertaining to any of the unemancipated
children been entered by the Family Support Division?
Yes, I have attached a copy of the order to this petition.
No
49. Are you or your spouse currently receiving benefits pursuant
to TANF?
Yes
No
Unknown
Petition for Dissolution of Marriage – Page 11 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Do not leave these questions blank if
there are unemancipated children.
____________________________________________________________________
50. Are there any other allegations?
____________________________________________________________________
____________________________________________________________________
If there are any other statements you
wish to include in your petition, you should
enter them here. Specific allegations of
misconduct are not necessary unless and
until your spouse denies that the marriage is
irretrievably broken.
____________________________________________________________________
Request for
Relief
I want the court to do the following: (Check all that apply)
Grant a dissolution of my marriage
Grant custody of the child(ren) of the marriage as stated herein (if applicable)
Enter appropriate orders with respect to the support of the child(ren) (if
applicable)
Divide the marital property and debts
Award maintenance to me
Award maintenance to my spouse
Change my name to my former name of _____________________________.
I am without sufficient funds to pay for my attorney and I request that the other
party pay my attorney’s fees.
Other (Please state the other requests)
_________________________________________________________________
_________________________________________________________________
Petitioner, of lawful age, being duly sworn on his or her oath states that he or she is the petitioner named
above and that the facts stated in the Petition for Dissolution of Marriage are true according to his or her
best knowledge and belief.
►__________________________________
Petitioner – SIGN HERE
__________________________________
Petitioner – PRINT YOUR NAME HERE
Subscribed and sworn to this _____ day of __________________, 20____.
________________________
Notary Public
You must sign this petition
in front of a Notary Public.
My Commission Expires:
_____________________
ATTORNEY INFORMATION (May be completed by your attorney)
________________________________________
Attorney – SIGN HERE
___________________
Missouri Bar Number
_________________________________________________________
Attorney for Petitioner – PRINT YOUR NAME HERE
_________________________________________________________
(Street)
_________________________
(City)
_________________
(Telephone Number)
__________________
(State)
_________________
(Fax Number)
___________
(Zip)
______________________
(Email Address)
Do not enter any
information here if you are
filing this case without the
assistance of a lawyer.
This information may be
completed by your attorney.
I have assisted Petitioner in
the preparation of these
pleadings, but I am not
entering my appearance on
behalf of Petitioner.
Petition for Dissolution of Marriage – Page 12 of 12
Form CAFC001-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Country
Choose one...
Choose one...
Country
Choose one...
Choose one...
State or Country of Marriage
Country
Choose one...
Circuit Clerk
Form CAFC065-04/01/2009
Print Income and Expenses
Clear All Forms
Table of Contents
Form CAFC050 - Income and Expense Statement
For use in Dissolution of Marriage Cases
In what Missouri County is this case to
be decided?
What is the case number? (This number
In the Circuit Court of
MISSOURI
Case Number
Information
shown in blue
on this form
does not print.
Division Number
is assigned at time of filing)
Answer all questions on this form completely.
Your
Information
My full name is:
___________________
(First Name)
______________
(Middle Name)
________________________________
(Last Name)
________
(Jr./Sr./III)
I filed this case. (I am the Petitioner)
I did not file this case. (I am the Respondent)
Other Party’s
Information
Monthly
Income
Information
Form 14
The full name of my husband or wife is:
___________________
(First Name)
______________
(Middle Name)
________________________________
(Last Name)
Wife
Husband
1. Monthly Gross Income from Salaries, Wages and
Commissions including Bonuses
________________
________________
2. Monthly Self-Employment Income
________________
________________
3. Imputed Monthly Income
________________
________________
4. Monthly Social Security Benefits not including
Supplemental Security Income (SSI)
________________
________________
5. Monthly Retirement Benefits
________________
________________
6. Monthly Pension Income
________________
________________
7. Monthly Interest Income
________________
________________
8. Monthly Trust and Annuity Income
________________
________________
9. Monthly Income from Dividends and Partnership
Distributions
________________
________________
10. Monthly Unemployment Compensation Benefits
________________
________________
11. Monthly Severance Pay
________________
________________
12. Monthly Worker’s Compensation Benefits
________________
________________
Statement of Income and Expenses - Page 1 of 3
Form CAFC050-07/01/2012
________
(Jr./Sr./III)
This form is available for free at www.selfrepresent.mo.gov
Monthly
Income
Information
(Continued)
Wife
Husband
13. Monthly Disability Insurance Benefits
________________
________________
14. Monthly Veterans Disability Benefits
________________
________________
15. Monthly Military Allowances for Subsistence and
Quarters
________________
________________
16.
Total Monthly Gross Income from
Paragraphs 1 through 15 (Also enter on Form 14
________________
________________
These numbers are automatically calculated for you as you fill in this form.
– Line 1)
17. Monthly Supplemental Security Income Benefits (SSI)
________________
________________
18. Monthly Payments of Temporary Assistance for Needy
Families (TANF)
________________
________________
19. Monthly Medicaid Benefits
________________
________________
20. Food Stamps
________________
________________
21. Number of unemancipated children who are NOT the
subject of this proceeding that primarily reside with
each party (also enter on Form 14 – Line 2c(1))
Monthly amount of child support received pursuant to a
court or administrative order for unemancipated
children who are NOT the subject of this proceeding
that primarily reside with each party (Also enter on
Form 14 – Line 2c(3))
_______
_______
________________
________________
22. Monthly Maintenance Received in THIS case
________________
________________
23. Monthly Maintenance Received in OTHER cases
________________
________________
24. Total Monthly court ordered maintenance being
________________
________________
received. Add lines 22 and 23. (Form 14 – Line 1a)
These numbers are automatically calculated for you as you fill in this form.
Monthly
Expense
Information
Form 14
Wife
Husband
25. Monthly court or administratively ordered child support
being paid for children who are NOT the subject of this
Proceeding (Form 14 – Line 2a)
________________
________________
26. Monthly Maintenance Paid in THIS case
________________
________________
27. Monthly Maintenance Paid in OTHER cases
________________
________________
28. Total Monthly Court Ordered Maintenance being Paid.
________________
________________
Add lines 26 and 27. (Form 14 – Line 2b)
These numbers are automatically calculated for you as you fill in this form.
29. Reasonable work-related child care costs of each party
Paragraph 10
for the children who are the subject of this proceeding
________________
________________
(Form 14 – Line 6a and Line 6b)
30. Health insurance costs for the children who are the
subject of this proceeding (Form 14 – Line 6c)
31. Uninsured extraordinary medical costs for the children
who are the subject of this proceeding (Form 14 – Line
6d)
32. Other extraordinary child rearing costs for the children
who are the subject of this proceeding (Form 14- Line
6e)
33. All Other Expenses of each person (Include housing
costs, utilities, transportation costs, food, clothing, loan
payments, charitable contributions, entertainment,
insurance other than listed on line 30, etc.)
________________
________________
Paragraph 5
________________
________________
Paragraph 9
________________
________________
Paragraph 14a
________________
________________
Statement of Income and Expenses - Page 2 of 3
Form CAFC050-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
I certify under oath that I have given the other party a copy of this Income and Expense Statement pursuant to Supreme
Court Rule 43.01(d) by: (You MUST check at least ONE of the following five boxes)
Serving a copy with the original pleadings herein.
Mailing a copy to the other party or his or her attorney on ____________________ (Date) at the following address:
________________________________________________________________________
(Street)
_________________________
__________________
______________
(City)
(State)
(Zip)
Handing a copy to the other party or his or her attorney on ____________________(Date).
Sending a copy to the other party or his or her attorney by fax to
_______________ (fax number) on ____________________ (Date) at ____________ (Time).
Sending a copy via electronic mail to the other party or his or her attorney at
____________________________________________ (Email Address) on ____________________ (Date).
Instructions: The following information MUST be filled in before a notary public. This Income and Expense Statement is required to be verified before a notary
public. The “Affiant” is the person that is completing this document.
COUNTY OF ________________
STATE OF _________________
)
) ss.
)
Affiant, of lawful age, being duly sworn on his or her oath, states that he or she is the affiant named herein and
that the facts stated in this Income and Expense Statement are true according to his or her best knowledge
and belief.
►__________________________________
Affiant – SIGN HERE
_______________________________________
Affiant – PRINT YOUR NAME HERE
Subscribed and sworn to on ____________________.
__________________________________
Notary Public
Sign here in front of
a Notary Public
My Commission Expires: _________________________
Statement of Income and Expenses - Page 3 of 3
Form CAFC050-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Table of Contents
Form CAFC040 - Directions and Information
Do I have to file
this form?
Yes. You must file Form CAFC040 with either your “Petition for Dissolution of Marriage”
or your “Answer,” even if it is not signed by both parties. You should not file these
directions with the court.
What is marital
property?
§452.330, RSMo. defines “marital property.” Usually marital property is property
acquired by either spouse during the marriage of the parties other than property
acquired by gift, inheritance, or in exchange for nonmarital property. This means that
all wages earned during the marriage are martial property. All property owned by the
parties is presumed to be marital property.
Nonmarital property can be converted to marital property by placing a spouse’s
name on an account or title. Also, a marital interest can be acquired in nonmarital
property by the contribution of marital assets to the increase in value of the nonmarital
property. Finally, income from nonmarital property during the marriage of the parties is
marital property.
What is
nonmarital
property?
“Nonmarital property” is property that was acquired prior to the marriage or
property that was acquired during the marriage by gift, inheritance, or in exchange for
nonmarital property. Nonmarital property is sometimes also called “separate
property.” Additionally, some state teacher retirement benefits are considered
nonmarital. §169.572, RSMo.
Can property be
marital and
nonmarital?
Yes. If an item of property is partly marital and partly nonmarital, then it should be
listed under both the marital and nonmarital sections. For example, if one party had
earned pension benefits for five years prior to the marriage and continued to earn the
same pension benefits for five years during the marriage, one-half or 50% of the
pension and retirement benefits are marital and one-half or 50% are nonmarital. In
that situation, the pension and retirement benefits would be listed both under marital
and nonmarital property.
What is “fair
market value”?
This is the amount someone would pay for this item of property today. It is not what
the property cost when you purchased it. A ten year old automobile has a value far less
than the amount you paid for the automobile.
What if I don’t
agree with this
proposed
separation
agreement?
You must take appropriate actions to protect your interests. CONSULT A LAWYER.
Do not fail to respond if you have been served with these papers as the court may
proceed without any further notice to you.
Do we have to
list our property
even if we’ve
already divided
it?
Yes, all property and all debt must still be included on one of the tables.
Directions and Information for completing Form CAFC040 - Statement of Property and Debt and
Proposed Separation Agreement –Page 1 of 3
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
What property
should I list on
this form?
•
ALL PROPERTY AND MARITAL DEBT must be divided in a dissolution of marriage
proceeding. Your dissolution of marriage may not be final unless this is done.
This includes the following types of property and debt:
Real estate, motor vehicles, bank accounts, pension and retirement plans and
profit sharing plans, stocks, bonds or other securities, life insurance, cash on hand,
household goods, personal goods, trust interests, businesses or partnerships, debts
owed to you or your spouse by others, any interests in pending litigation or suits to be
filed, farm equipment, animals or crops, interests in contracts made and not
performed, and any other assets.
Do I have to list
property even if
my spouse’s
name is not on
it?
Yes, you must list all property owned by you alone, by your spouse alone, and by you
and your spouse together. You must list property even if it is not in joint names. Any
property in which either you or your spouse claim ANY interest whatsoever MUST be
listed.
In many instances, you will not be able to sell your property or receive your
retirement unless you prove that these items were listed in your dissolution of marriage
judgment.
Do I have to list
property that
either of us is
buying at the
present time?
YES. You must list all property that either you or your spouse is purchasing by
making monthly payments. So, even if you owe money on your car or home, it still must
be listed. Actually, it must be listed twice: once as an item of property and once as a
debt secured by the property.
Do I have to list
property I owned
before the
marriage?
Yes. This is normally nonmarital property, but under some circumstances it may be
considered marital property.
Do I have to list
property my
spouse owned
before the
marriage?
Yes. Just as you had to list property you owned before the marriage, you should
also list property your spouse owned before the marriage. Once again, this is normally
nonmarital property, but under some circumstances it may be considered marital
property.
I don’t know what
my spouse owns
You should hire a lawyer to assist you. A lawyer has the ability to assist you in
locating
the assets of your spouse.
so how can I list
it?
Directions and Information for completing Form CAFC040 - Statement of Property and Debt and
Proposed Separation Agreement –Page 2 of 3
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Do I have to list
property I
Yes. You are still married, so any property or debt that you have acquired since your
acquired after we separation has to be included.
separated?
What happens if I
don’t list all the
property and
marital debt?
It would be a VERY BIG mistake not to list all your property and marital debt. Your
dissolution of marriage may not be final, and your spouse will be able to come back in
the future and try and get this item of property. In some cases, you may not be able to
receive your pension or sell your property without proof that your dissolution of
marriage judgment listed the property.
Should I list my
pension even
though I can’t
receive any
benefits now?
Yes. It is very important that you list all pension plans in which you or your spouse
participate. They should be listed even if you can’t receive any benefits for a long time.
If you don’t list a pension plan, you may not be able to receive any benefits in the
future without further legal proceedings.
Do I have to list
every last dish
and towel?
No. You do not need to list property if it is of minimal value. If the item of property
is worth less than $100.00, you may omit it from your list.
What if I acquire
some property or
debt after I file
my case?
If you acquire any additional property or debt during the time this case is pending,
you must notify the court of that fact at the time of your hearing. If you dispose of any
property or pay off any debt during the time this case is pending, you must notify the
court of that fact at the time of your hearing.
What if I need
more space on
the tables?
You may make copies of any of the four tables if you need additional room for more
property or debt. When you have listed all the property and debt, you should number
the pages. Make sure you write “Not Applicable” or “N/A” in each box under “Item of
Property” or “Item of Debt” that you do not fill. (Someone could fill this in later with
some other information)
IMPORTANT
This document is placed in a court file, which is an open document available to the
public. In listing your bank or other accounts, or your credit card or other debt, do not
include the entire account number. You should include only enough information to
distinguish your account from other accounts owned by you and your spouse. For
example, in listing a credit card number, you should include only the last four digits of
the account, such as xxxx-xxxx-xxxx-1234.
Directions and Information for completing Form CAFC040 - Statement of Property and Debt and
Proposed Separation Agreement –Page 3 of 3
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Print Income and Expenses
Clear All Forms
Table of Contents
Form CAFC040 - Property and Debt Statement and Proposed
Separation Agreement (For use in Dissolution of Marriage Cases)
Information
In what Missouri county will this case
be filed?
In the Circuit Court of
What is the case number of the
pending case?
Case Number
shown in blue
on this form
does not print.
MISSOURI
Division Number
Answer all questions on this form completely.
Petitioner’s
Information
The full name of the person that filed this case is:
___________________
(First Name)
______________
(Middle Name)
________________________________
(Last Name)
________
(Jr./Sr./III)
Wife filed this case and is the Petitioner.
Husband filed this case and is the Petitioner.
Respondent’s
Information
The full name of the person that did NOT file this case:
___________________
(First Name)
______________
(Middle Name)
________________________________
(Last Name)
________
(Jr./Sr./III)
What does this
form cover?
There are two parts to this document. Part One is your division of property and debt
and Part Two pertains to spousal support or “maintenance.” This document does not
have anything to do with child support or custody. Issues addressing child support and
custody are contained in a parenting plan.
What is a
Separation
Agreement?
It is an agreement in which you and your spouse agree to a distribution of property
and debt and to provisions concerning maintenance and attorney’s fees. If both you
and your spouse sign this document, it is called a “Separation Agreement.” It does not
include provisions for child custody and child support.
Even if both you and your spouse have signed the agreement, the court is not
bound by it. If the court finds that your agreement is “unconscionable” or does not
divide all property and marital debt, it will not be approved by the court. The court can
divide the property in any manner it considers fair, and it may or may not order
maintenance to be paid.
How do I
complete Part
One of this
Form?
You must list all of your marital and nonmarital property and marital debt on one of
the four tables.
Use a separate row for each item of property or debt. You should draw a line
through all rows that do not contain an item of property. This is very important because
someone could alter this document after you have signed it. Keep a copy of this
document after you have signed it.
Statement of Property and Debt and Proposed Separation Agreement – Page 1 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Part One – Division of Property and Debt
You must answer “Yes” or “No” to each of the following questions.
Property
Owned by
Wife
Does Wife own a house, condominium or other real estate?
Yes
No
Does Wife own a car, truck or motorcycle?
Yes
No
Does Wife own a mobile home, trailer, boat or airplane?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(You should attach a copy of the deed for each item of real estate to this form)
Does Wife have any bank accounts?
(either alone or
with anyone else) Does Wife have any right to receive any pension or retirement
benefits other than Social Security?
Does Wife have an IRA or 401(k) or other retirement account?
Does Wife have any furniture, appliances or other household goods
worth more than $100?
Does Wife have any jewelry, clothing or other personal items worth
more than $100?
Does Wife own a business?
Property
Owned by
Husband
Yes
No
Does Wife own any stocks or bond?
Yes
No
Does Wife have any life insurance that could be cashed in?
Yes
No
Does anyone owe Wife any money?
Yes
No
Does Wife have any lawsuits against anyone?
Yes
No
Does Wife have any farm equipment, animals or crops?
Yes
No
Does Wife have any interest in any trusts?
Yes
No
Does Wife have any other asset or property?
Yes
No
Does Husband own a house, condominium or other real estate?
Yes
No
Does Husband own a car, truck or motorcycle?
Yes
No
Does Husband own a mobile home, trailer, boat or airplane?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Does Husband own any stocks or bond?
Yes
No
Does Husband have any life insurance that could be cashed in?
Yes
No
Does anyone owe Husband any money?
Yes
No
Does Husband have any lawsuits against anyone?
Yes
No
Does Husband have any farm equipment, animals or crops?
Yes
No
Does Husband have any interest in any trusts?
Yes
No
Does Husband have any other asset or property?
Yes
No
(You should attach a copy of the deed for each item of real estate to this form)
Does Husband have any bank accounts?
(either alone or
with anyone else) Does Husband have any right to receive any pension or retirement
benefits other than Social Security?
Does Husband have an IRA or 401(k) or other retirement account?
Does Husband have any furniture, appliances or other household
goods worth more than $100?
Does Husband have any jewelry, clothing or other personal items
worth more than $100?
Does Husband own a business?
If you answered “Yes” to any of the above questions, you
must list each item of property in either Table 1 or Table 2 on
the following pages.
Statement of Property and Debt and Proposed Separation Agreement – Page 2 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
TABLE 1. PROPERTY TO BE AWARDED TO WIFE - The following property is to become the sole and separate property
of WIFE.
Item of Property
Present Fair
Market Value
Is there an
amount owed
on this
property?
Is this marital or
nonmarital
property?
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Statement of Property and Debt and Proposed Separation Agreement – Page 3 of 9
Form CAFC040-07/01/2012
Party with
Possession of
this Property
This form is available for free at www.selfrepresent.mo.gov
TABLE 2. PROPERTY TO BE AWARDED TO HUSBAND - The following property is to become the sole and separate
property of HUSBAND.
Item of Property
Present Fair
Market Value
Is there an
amount owed
on this
property?
Is this marital or
nonmarital
property?
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
(Do not deduct amount
owed from this value)
Yes - List debt
in Tables 3 or 4.
No
Marital
Nonmarital
Both
Wife
Husband
Other
Statement of Property and Debt and Proposed Separation Agreement – Page 4 of 9
Form CAFC040-07/01/2012
Party with
Possession of
this Property
This form is available for free at www.selfrepresent.mo.gov
Debts that
Wife Owes
Does Wife owe a mortgage on a house or condominium or land?
Yes
No
Does Wife owe money on a car?
Yes
No
Does Wife owe money on any credit cards?
Yes
No
Yes
No
Is Wife currently in a bankruptcy proceeding? (Chapter 7 or Chapter 13)
Yes
No
Does Wife owe any medical or dental bills?
Yes
No
Does Wife owe any other debts?
Yes
No
Yes
No
(either alone or
with anyone else) Does Wife owe any money to any family or friends?
Debts that
Husband
Owes (either
alone or with
anyone else)
Does Husband owe a mortgage on a house or condominium or
land?
Does Husband owe money on a car?
Yes
No
Does Husband owe money on any credit cards?
Yes
No
Does Husband owe any money to any family or friends?
Is Husband currently in a bankruptcy proceeding? (Chapter 7 or
Yes
No
Yes
No
Does Husband owe any medical or dental bills?
Yes
No
Does Husband owe any other debts?
Yes
No
Chapter 13)
If you answered “Yes” to any of the above questions, you
must list each item of debt in either Table 3 or Table 4 on the
following pages.
What debts
should I list on
this form?
You should list all loans from any individual, bank, credit card company, credit
union, savings and loan association or other lending institution. Include all debts owed
by either you or your spouse. Make sure to list all credit cards and any amounts owed
pursuant to any bankruptcy or other repayment plans.
Debts that the Wife should pay are to be listed in Table 3 and Debts that the
Husband should pay are to be listed in Table 4.
What does
“security” mean?
The mortgage on a home is traditionally secured by the home. When you finance
the purchase of an automobile, the company that loans you the money is listed on the
title to the automobile. They too have a security interest in your car. Usually, a debt is
secured by an item of property if the person to whom you owe the money can take the
item of property if you fail to pay the debt. The schedules of debt ask you to list any
security for that debt. You must also list the property that secures the debt under the
property listings.
How do you get
the other party’s
name off of this
debt?
This agreement does not affect the rights of the person to whom you or your spouse
owe the money. They can still collect the money from both or your spouse.
Each party is to attempt to refinance or obtain the release of any liability of the
other party as soon as reasonably practicable after the dissolution of marriage.
Statement of Property and Debt and Proposed Separation Agreement – Page 5 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
TABLE 3. DEBTS TO BE PAID BY WIFE - List all loans from any individual, bank, credit card company, credit union,
savings and loan association or other lending institution that are to be paid by WIFE. Wife is to indemnify and hold Husband harmless
for all debts listed on Table 3.
The creditor’s rights to collect these debts from Husband are NOT affected without the consent of the creditor. Wife is to
refinance or obtain the release of any liability of Husband on all debts listed in Table 3 as soon as reasonably practicable.
Item of Debt
(Who is the money owed to?)
Current
Balance
Monthly
Payment
What is the security for
this debt, if any?
(This property should be listed in
Table 1 or Table 2)
Marital or Separate
Debt
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Statement of Property and Debt and Proposed Separation Agreement – Page 6 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
TABLE 4. DEBTS TO BE PAID BY HUSBAND - List all loans from any individual, bank, credit card company, credit
union, savings and loan association or other lending institution that are to be paid by HUSBAND. Husband is to indemnify and hold
Wife harmless for all debts listed on Table 4.
The creditor’s rights to collect these debts from Wife are NOT affected without the consent of the creditor. Husband is to
refinance or obtain the release of any liability of Wife on all debts listed in Table 4 as soon as reasonably practicable.
Item of Debt
(Who is the money owed to?)
Current
Balance
Monthly
Payment
What is the security for
this debt, if any?
(This property should be listed in
Table 1 or Table 2)
Marital or Separate
Debt
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Marital
Nonmarital
Both
Statement of Property and Debt and Proposed Separation Agreement – Page 7 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Part Two – Maintenance and Other Provisions
What is
maintenance?
Maintenance is money paid on a regular schedule by one spouse to the other for
support after the dissolution of marriage. It may be for a set period of time or it may be
for an indefinite period of time. It usually terminates upon the death of either party or
the remarriage of the party receiving maintenance unless the parties agree otherwise.
It may or may not be subject to future modification upon a showing of changed
circumstances. Maintenance used to be referred to as “alimony.”
Maintenance to
Wife
The court lacks jurisdiction to enter any orders with respect to maintenance of
Wife.
No maintenance is to be paid to Wife by Husband. This agreement is not subject to
modification.
Husband shall pay to Wife the sum of ____________ per month as and for
maintenance. Said maintenance is _______ subject to modification. Said
maintenance shall terminate upon the death of either party, the remarriage of Wife, or
at such earlier time as set forth herein.
________________________________________________________________________
________________________________________________________________________
Maintenance to
Husband
The court lacks jurisdiction to enter any orders with respect to maintenance of
Husband.
No maintenance is to be paid to Husband by Wife. This agreement is not subject to
modification.
Wife shall pay to Husband the sum of ____________ per month as and for
maintenance. Said maintenance is _______ subject to modification. Said
maintenance shall terminate upon the death of either party, the remarriage of
Husband, or at such earlier time as set forth herein.
________________________________________________________________________
________________________________________________________________________
Wage
Withholding for
Maintenance
(Answer only if maintenance is to be paid by either party.)
Income withholding shall be prepared by the person receiving maintenance and
issued by the Circuit Clerk upon the effective date of this order.
Income withholding shall not issue for the following reason(s):
________________________________________________________________________
Additional
Provisions
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Statement of Property and Debt and Proposed Separation Agreement – Page 8 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
I certify under oath that I have given the other party a copy of this Property and Debt Statement pursuant to Supreme Court
Rule 43.01(d) by: (You MUST check at least ONE of the following five boxes)
Serving a copy with the original pleadings herein.
Mailing a copy to the other party or his or her attorney on ____________________ (Date) at the following address:
________________________________________________________________________
(Street)
_________________________
__________________
______________
(City)
(State)
(Zip)
Handing a copy to the other party or his or her attorney on ____________________(Date).
Sending a copy to the other party or his or her attorney by fax to
_______________ (fax number) on ____________________ (Date) at ____________ (Time).
Sending a copy via electronic mail to the other party or his or her attorney at
____________________________________________ (Email Address) on ____________________ (Date).
Instructions: The following information MUST be filled in before a notary public. Your Statement of Property and Debt is required to be verified before
a notary public.
COUNTY OF ______________ )
) ss.
STATE OF ________________ )
Wife, of lawful age, being duly sworn on her oath, states that she is the Wife named herein and
that the facts stated in this Statement of Property and Debt are true according her best knowledge and
belief, and that she agrees with the terms and conditions set forth herein.
Further, Wife states that she executed this Statement of Property and Debt as her free act and
deed.
►__________________________________
WIFE – SIGN HERE
__________________________________
WIFE – PRINT YOUR NAME HERE
Subscribed and sworn to this _____ day of __________________, 20____.
________________________
Notary Public
My Commission Expires:
COUNTY OF ______________ )
) ss.
STATE OF ________________ )
Husband, of lawful age, being duly sworn on his oath, states that he is the Husband named
herein and that the facts stated in this Statement of Property and Debt are true according his best
knowledge and belief, and that he agrees with the terms and conditions set forth herein.
Further, Husband states that he executed this Statement of Property and Debt as his free act and
deed.
►__________________________________
HUSBAND – SIGN HERE
__________________________________
HUSBAND – PRINT YOUR NAME HERE
Subscribed and sworn to this _____ day of __________________, 20____.
________________________
Notary Public
My Commission Expires:
Statement of Property and Debt and Proposed Separation Agreement – Page 9 of 9
Form CAFC040-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Print Respondent's Answer
Clear All Forms
Table of Contents
IN THE CIRCUIT COURT OF _________________________, MISSOURI
(County where court is located)
In re the Marriage of
_________________
_____________
____________________
(First)
(Middle)
(Last)
Petitioner, (Your full name should be entered here)
_________
(Jr./Sr./III)
Case No. ____________
(Will be assigned when case is filed)
-andDivision No. ____________
_________________
_____________
____________________
(First)
(Middle)
(Last)
Respondent. (Enter your spouse’s full name here)
_________
(Jr./Sr./III)
(Will be assigned when case is filed)
Respondent’s Answer to Petitioner’s
Petition for Dissolution of Marriage
1. I am answering the following pleading (One of the following MUST be checked)
The first petition my spouse filed in this case (Original Petition)
The second petition my spouse filed in this case (First Amended Petition)
The third petition my spouse filed in this case (Second Amended Petition)
2. I understand that by voluntarily entering my appearance and filing this pleading, I am subjecting myself
to the jurisdiction of this court, and the court may enter such orders and judgments as are authorized by
law, including orders awarding maintenance (formerly alimony), child support, child custody, parenting
time/visitation, division of property, division of debts, and attorney’s fees.
3. I admit as true EVERYTHING my spouse stated in his or her Petition for Dissolution of Marriage and
incorporate all of those allegations herein EXCEPT the following:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Instructions: Any allegation not specifically denied will be deemed admitted and you will not have the opportunity to disagree with this allegation when
the case is presented to the court. Identify each paragraph that contains any allegation with which you disagree.
4. What are the last four numbers of your social security number?
XXX-XX-______________
(Social Security Number)
Instructions: The last four digits of your social security number are required by §452.312.2(6), RSMo.
5. Check ONE of the following boxes:
I am not on active duty in the armed services of the United States of America.
I am on active duty in the armed services of the United States of America, but waive my rights
pursuant to the Servicemembers Civil Relief Act of 2003.
Respondent’s Answer to Petitioner’s Petition for Dissolution of Marriage - Page 1 of 3
Form CAFC010-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Request for
Relief
I want the court to do the following: (Check all that apply)
Grant a dissolution of my marriage
Grant custody of the child(ren) of the marriage as stated herein (if applicable)
Enter appropriate orders with respect to the support of the child(ren) (if
applicable)
Divide the marital property and debts
Award maintenance to me
Award maintenance to my spouse
Change my name to my former name of _____________________________.
I am without sufficient funds to pay for my attorney and I request that the other
party pay my attorney’s fees.
Other (Please state the other requests)
_________________________________________________________________
_________________________________________________________________
I certify under oath that I have given the other party a copy of this Answer pursuant to Supreme Court Rule 43.01(d) by:
(You MUST check at least ONE of the following five boxes)
Mailing a copy to the other party or his or her attorney on ____________________ (Date) at the following address:
________________________________________________________________________
(Street)
_________________________
__________________
______________
(City)
(State)
(Zip)
Handing a copy to the other party or his or her attorney on ____________________(Date).
Sending a copy to the other party or his or her attorney by fax to
_______________ (fax number) on ____________________ (Date) at ____________ (Time).
Sending a copy via electronic mail to the other party or his or her attorney at
____________________________________________ (Email Address) on ____________________ (Date).
NOTICE
Some local rules may also require that you file an income and expense statement and a property statement at the
time you file your answer. Failure to do so could cause your answer to be stricken. Also, if there are any unemancipated
children, you are required to file a proposed parenting plan within 30 days after the date you were served or the date you
filed this answer. You may file a joint parenting plan with your spouse. See §452.310.7, RSMo.
MAILING ADDRESS OF RESPONDENT (THIS MUST BE COMPLETED)
If you do not complete this portion of this document, the court will have no way to notify you of court dates and other
proceedings in your case. The court will then be forced to proceed without giving you notice.
_________________________________________________________
(Street)
_________________________
(City)
__________________
(State)
___________
(Zip)
_________________________
(Telephone Number)
_____________________________
(E-Mail Address - Optional)
This is the address that the court will use to send information concerning your case to you. If you move during the time this case is pending, you must
send a letter to the court notifying it of your new address. It is your duty to keep the court informed as to your correct address.
This address is not necessarily the same as the address at which you reside. Even if you do not wish to disclose the address at which you
reside, you MUST still provide the court with a mailing address.
Respondent’s Answer to Petitioner’s Petition for Dissolution of Marriage - Page 2 of 3
Form CAFC010-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Instructions: The following information MUST be filled in before a notary public. Your answer is required
to be verified before a notary public. §452.310.1, RSMo.
COUNTY OF __________
STATE OF ____________
}
} ss.
}
Respondent, of lawful age, being duly sworn on his or her oath, states that he or she is the respondent
named above and that the facts stated in Respondent’s Answer to Petitioner’s Petition for Dissolution of
Marriage are true according to his or her best knowledge and belief.
►__________________________________
Respondent – SIGN HERE
__________________________________
Respondent – PRINT YOUR NAME HERE
Subscribed and sworn to this _____ day of __________________, 20____.
________________________
Notary Public
The Respondent must sign
this answer in front of a
Notary Public.
My Commission Expires:
_____________________
ATTORNEY INFORMATION (May be completed by your attorney)
________________________________________
Attorney – SIGN HERE
___________________
Missouri Bar Number
_________________________________________________________
Attorney for Respondent – PRINT YOUR NAME HERE
_________________________________________________________
(Street)
_________________________
(City)
_________________
(Telephone Number)
__________________
(State)
_________________
(Fax Number)
___________
(Zip)
______________________
(Email Address)
Do not enter any
information here if you are
filing this answer without the
assistance of a lawyer.
This information may be
completed by your attorney.
I have assisted Respondent
in the preparation of these
pleadings, but I am not
entering my appearance on
behalf of Respondent.
Respondent’s Answer to Petitioner’s Petition for Dissolution of Marriage - Page 3 of 3
Form CAFC010-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Print Judgment
Clear All Forms
Table of Contents
Approved for Use in Uncontested Cases Only
IN THE CIRCUIT COURT OF _________________________, MISSOURI
In re the Marriage of
_________________
(First)
_____________
(Middle)
____________________
(Last)
_________
(Jr./Sr./III)
Petitioner,
Case No. ____________
-andDivision No. ____________
_________________
(First)
_____________
(Middle)
____________________
(Last)
_________
(Jr./Sr./III)
Respondent.
Judgment of Dissolution of Marriage
Parties
1.
As used herein, “Wife” refers to Petitioner and “Husband” refers to Respondent.
As used herein, “Husband” refers to Petitioner and “Wife” refers to Respondent.
2. Appearances (Check all that apply)
Wife appears in person.
Husband appears in
person.
Third Party _____________
appears in person.
Wife appears by
attorney.
Husband appears by
attorney.
Third Party ___________
appears by attorney.
Guardian ad Litem
appears in person.
Cause submitted upon
affidavit of Wife.
Cause submitted upon
affidavit of Husband.
3. The last four digits of Wife’s Social Security Number are ___________ and the last four digits of
Husband’s Social Security Number are ___________.
4.
Respondent is not on active duty in the armed services of the United States now or any time
since the filing of the petition herein.
Respondent is on active duty in the armed services of the United States, but has waived his
or her rights pursuant to the Servicemembers Civil Relief Act of 2003.
Jurisdiction
5. Thirty (30) days have elapsed since the filing of the petition herein.
6.
7.
The court has personal jurisdiction over Respondent.
The court does not have personal jurisdiction over Respondent.
Wife has been a resident of the State of Missouri for at least 90 days immediately prior to the
filing of the petition herein.
Husband has been a resident of the State of Missouri for at least 90 days immediately prior
to the filing of the petition herein.
Judgment of Dissolution of Marriage – Page 1 of 5
Form CAFC070-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Marriage
8. The parties were married on _____________________, and the marriage was registered in
______________________________________________________________________.
9. The parties continued to live together until ________________________, on or about which date
they separated.
10. There is no reasonable likelihood that the marriage of the parties can be preserved, and the
marriage is, therefore, irretrievably broken.
Children
11. Wife is not now pregnant.
12.
There are no unemancipated children born or adopted of the marriage.
There is/are ___________ unemancipated living child(ren) born or adopted of the marriage.
The name(s) and age(s) of said child(ren) are:
Name of Child
Age
As used herein, “minor child(ren)” refers to the unemancipated living child(ren) listed above.
__________________________________________________________________________________________
__________________________________________________________________________________________
It is therefore ordered, adjudged and decreed that:
13. The marriage of Wife and Husband is dissolved.
Maintenance
14. Maintenance to Wife
No maintenance is to be paid to Wife by Husband. This order is not subject to modification.
Husband is ordered to pay to Wife the sum of ____________ per month as and for
maintenance. Said maintenance is _______ subject to modification.
__________________________________________________________________________________________
__________________________________________________________________________________________
The court lacks jurisdiction to enter any orders with respect to maintenance of Wife.
Judgment of Dissolution of Marriage – Page 2 of 5
Form CAFC070-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
15. Maintenance to Husband
No maintenance is to be paid to Husband by Wife. This order is not subject to modification.
Wife is ordered to pay to Husband the sum of ____________ per month as and for
maintenance. Said maintenance is _______ subject to modification.
__________________________________________________________________________________________
__________________________________________________________________________________________
The court lacks jurisdiction to enter any orders with respect to maintenance of Husband.
16. Wage Assignment for Maintenance (If maintenance is to be paid by either party)
Income withholding shall be prepared by the obligee and issued by the Circuit Clerk upon the
effective date of this order.
Income withholding shall not issue for the following reason(s):
_________________________________________________________________________________________.
Child Custody (If there are unemancipated children)
17.
The court does NOT have “jurisdiction” (as defined in the Uniform Child Custody Jurisdiction
and Enforcement Act, §452.700, RSMo et seq.) over the custody arrangements of the minor
child(ren) and, therefore, enters no further orders with respect to the custodial arrangements of
the minor child(ren).
The court has “jurisdiction” (as defined in the Uniform Child Custody Jurisdiction and
Enforcement Act, §452.700, RSMo et seq.) over the custody arrangements of the minor
child(ren).
The court approves the provisions of Part A of the parenting plan marked exhibit _________
pertaining to the custodial arrangements of the minor child(ren) and finds that the custodial
arrangements contained in said parenting plan are in the best interests of the minor child(ren).
Therefore, the court orders the provisions of Part A of the said parenting plan pertaining to
the custodial arrangements of the minor child(ren) and incorporates by reference all of the terms
and conditions pertaining to the custodial arrangements of the minor child(ren) set forth in Part A
of said parenting plan as if fully set forth herein.
The sheriff or other law enforcement officers shall enforce the rights of any person to custody
or visitation pursuant to §452.425, RSMo.
__________________________________________________________________________________________
__________________________________________________________________________________________
Child Support (If there are unemancipated children)
18.
The court does not have jurisdiction to enter any orders with respect to the support of the
minor child(ren).
The court orders the provisions of Part B of the parenting plan marked exhibit _________ ,
pertaining to the support of the minor child(ren) and incorporates by reference all of the terms
and conditions set forth in Part B of said parenting plan as if fully set forth herein.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Judgment of Dissolution of Marriage – Page 3 of 5
Form CAFC070-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Marital and Nonmarital Property and Marital Debt
19. Division of Property
The parties have entered into a separation agreement marked exhibit ___________ that is
found to be not unconscionable. Said separation agreement is incorporated herein, and the
parties are ordered to perform the terms and conditions set forth therein as well as such further
and other orders contained in this judgment.
The parties have not entered into a separation agreement. All marital and non-marital
property and marital debt are divided in exhibit ___________. Said division is fair and equitable,
and the parties are ordered to perform the terms and conditions set forth therein.
20. Real Property
The legal description of the real property or properties divided herein is more fully set forth in
Exhibit(s) _________________, which is incorporated into and made a part of this judgment. The
Circuit Clerk is ordered to record a certified copy of this judgment with the Recorder of Deeds in
the following county or counties where the real property or properties is located:
__________________________________________________________________________________________
21. Pension and Retirement Plans
If this judgment divides any pension or retirement benefits, the court intends its judgment to be a
qualified domestic relations order and retains jurisdiction for the purpose of establishing or
maintaining this order as a qualified domestic relations order or to revise or conform its terms so
as to effectuate the expressed intent of this order.
22. Other Orders Concerning Property and Debt
________________ is ordered to pay to ________________ the sum of ____________ as and
for ______________________________________________________________________________.
23. This judgment divides all marital and nonmarital property and marital debt. No other marital or
non-marital property or marital debt remains to be divided by the court except as set forth herein.
Attorney’s Fees
24.
Neither party is awarded attorney’s fees from the other party.
Wife shall pay to _____________________ the sum of _____________ as and for Husband’s
attorney’s fees herein.
Husband shall pay to _____________________ the sum of _____________ as and for Wife’s
attorney’s fees herein.
Name Change
25.
The name of __________________________ is changed to ____________________________.
(Current Full Name)
(New Full Name)
Other Orders:
26.
Other orders are as per the attached Exhibit Number___________, which is incorporated by
reference as if fully set forth herein.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Judgment of Dissolution of Marriage – Page 4 of 5
Form CAFC070-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Court Costs
27.
Court costs are to be paid from the court cost deposit(s) previously posted.
Court costs are waived.
Waiver of Right to Rehearing (If case is heard by a Commissioner pursuant to
§487.010, RSMo et seq.)
We, the undersigned parties, do hereby acknowledge receipt of the findings and
recommendations of the commissioner and waive the right to file a motion for rehearing in this
case.
(If heard by a Family Court Judge)
(If heard by a Family Court Commissioner)
Findings and Recommendations of Commissioner:
__________________________
Judge
___________
Date
__________________________
Commissioner
___________
Date
All orders and these findings and recommendations
of the Commissioner are confirmed and adopted as
the judgment of the court.
__________________________
Judge
___________
Date
A certified copy of this judgment is to be mailed to the following person(s): (Check all applicable boxes)
Petitioner’s Attorney
Respondent’s Attorney
Guardian ad Litem
____________________________
____________________________
____________________________
(Signature of Petitioner’s Attorney)
(Signature of Respondent’s Attorney)
(Signature of Guardian ad Litem)
____________________________
(Street)
____________ ______ ______
(City)
(State) (Zip)
_________________________
(Telephone Number)
____________________________
(Street)
____________ ______ ______
(City)
(State) (Zip)
_________________________
(Telephone Number)
____________________________
(Street)
____________ ______ ______
(City)
(State) (Zip)
_________________________
(Telephone Number)
Petitioner
Respondent
____________________________
(Signature of Petitioner)
____________________________
(Street)
____________ ______ ______
(City)
(State) (Zip)
_________________________
(Telephone Number)
____________________________
(Signature of Respondent)
____________________________
(Street)
____________ ______ ______
(City)
(State) (Zip)
_________________________
(Telephone Number)
Third Party
____________________________
(Signature of Third Party)
____________________________
(Street)
____________ ______ ______
(City)
(State) (Zip)
_________________________
(Telephone Number)
Judgment of Dissolution of Marriage – Page 5 of 5
Form CAFC070-07/01/2012
This form is available for free at www.selfrepresent.mo.gov
Print Information Sheet
Clear All Forms
Table of Contents
Case Number (For Court Use Only) ___________________________
CONFIDENTIAL CASE FILING INFORMATION SHEET – DOMESTIC RELATIONS CASES
Required at Case Initiation and with Responsive Filings
INSTRUCTIONS:
9 Complete this form for all parties known at the time of filing. Provide the most appropriate Case Type and Party
Type codes and descriptions. (Found on the Case Types List and Party Types List at www.courts.mo.gov on the
Court Forms/Filing Information page.)
9 If additional space is needed, complete additional Confidential Case Filing Information Sheets.
NOTE: The full Social Security Number (SSN) is required pursuant to Section 509.520 RSMo if the party is a
person.
Filing Date:
County/City of St. Louis:
Style of Case:
(i.e. Petitioner v. Respondent)
Case Type Code:
Case Type Description:
Petitioner/Plaintiff Information:
Party Type Code:
Party Type Description:
Name: (Last)
(First)
(Middle)
Address:
City:
DOB:
State:
Gender:
Male
Female
Zip:
SSN:
Attorney Name (if represented by counsel):
Bar ID:
Party Type Code:
Respondent/Defendant Information:
Party Type Code:
Party Type Description:
Name: (Last)
(First)
(Middle)
Address:
City:
DOB:
State:
Gender:
Male
Female
Attorney Name (if represented by counsel):
Party Type Code:
Zip:
SSN:
Bar ID:
Party Type Code:
Party Type Description:
Name (if person): (Last)
(First)
(Middle)
Organization (if non-person):
Address:
City:
DOB:
State:
Gender:
Male
Female
SSN:
Attorney Name (if represented by counsel):
Party Type Code:
Zip:
Bar ID:
Party Type Code:
Party Type Description:
Name (if person): (Last)
(First)
(Middle)
Organization (if non-person):
Address:
City:
DOB:
State:
Gender:
Attorney Name (if represented by counsel):
OSCA (10-09) FI-10
Male
Female
Zip:
SSN:
Bar ID:
Party Type Code:
Case Number (For Court Use Only) ___________________________
Employer Information
Petitioner/Plaintiff Employer Name:
Employer Address:
City:
State:
Zip:
State:
Zip:
Respondent/Defendant Employer Name:
Employer Address:
City:
The following information regarding children is required. Complete this section for any child subject to the action of
this case.
*MACSS – Missouri Automated Child Support System
This Filing Information Sheet is applicable to how many children?
Children:
Name:
Gender:
SSN:
Male
Female
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
SSN:
Male
Female
SSN:
Male
Female
SSN:
Male
Female
SSN:
Male
Female
SSN:
Male
Female
SSN:
Male
Female
SSN:
Male
Female
SSN:
Male
Female
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
Optional: MACSS Member Number (to be completed by the court):
Name:
Gender:
DOB:
SSN:
Male
Female
DOB:
Optional: MACSS Member Number (to be completed by the court):
Check if more than ten children and attach additional sheet
Submitted by:
Bar ID (required if attorney):
Address (if not shown on previous page):
City:
Phone:
State:
Zip:
Email Address:
*IMPORTANT: It is the parties’ responsibility to keep the court informed of any change of address or employment.*
Instructions to Clerk
Maintain the closed portion(s) of the record in a sealed manila envelope within the file. The file can be
maintained with other open records. If a request is made to review the open portion of the file, the
envelope can be removed from the file. Access to the record must be restricted to avoid access to the
closed portion of the record.
OSCA (10-09) FI-10
Print Parenting Plan
Clear All Forms
Table of Contents
EXHIBIT NO. __________
IN THE CIRCUIT COURT OF _____________________, MISSOURI
(County where court is located)
_________________
(First)
_____________
(Middle)
____________________
(Last)
If this parenting plan is filed after
the case has been filed, you
MUST enter the Case Number.
_________
(Jr./Sr./III)
Petitioner/Plaintiff,
Case No. ____________
-andDivision No. ____________
_________________
(First)
_____________
(Middle)
____________________
(Last)
_________
(Jr./Sr./III)
Respondent/Defendant.
PARENTING PLAN
Part A – Custody of the Children
1. Identification of the Parties
Check one, and only one, of the following two boxes.
Mother is the Petitioner/Plaintiff. Father is the Respondent/Defendant.
Father is the Petitioner/Plaintiff. Mother is the Respondent/Defendant.
2. Plan Author(s)
Check all applicable boxes.
Court
Mother
Father
Guardian ad Litem
_________________________
3. Names and Ages of Children
Enter the total number of children to whom this parenting plan is applicable: ___________.
The names and ages of the children (hereinafter referred to simply as “the children”) are as follows:
Full Name of Child
Child’s Age
4. Duration of Plan
The terms and conditions set forth in this parenting plan shall remain in full force and effect until the
children are emancipated or until this plan is modified by a court of competent jurisdiction.
Parenting Plan Part A - Custody – Page 1
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Decisions Concerning the Children
“Joint legal custody” means that the parents share the decision-making rights, responsibilities, and authority
relating to the health, education and welfare of the child, and, unless allocated, apportioned, or decreed, the
parents shall confer with one another in the exercise of decision-making rights, responsibilities, and authority.
§452.375.1(2), RSMo.
5. Types of Decisions
The three types of decisions that parents must make concerning their children are major decisions, daily or
everyday decisions, and emergency decisions.
A. Major Decisions
Major decisions are the significant decisions about the children. Major decisions are made by the parent or
parents with legal custody. The following are examples of major decisions:
• The choice or change of schools, including college or special tutoring,
• The choice or change of physician, surgeon or dentist,
• Religious instruction, training or education,
• Selection of child care providers,
• Major medical care, surgery, or any medical procedure requiring hospitalization or out-patient surgery,
• Major dental work and orthodontia,
• Psychological or psychiatric treatment or counseling,
• The choice or change of camps or other special or extracurricular activities,
• The extent of any travel away from home,
• Part or full-time employment,
• Purchase or operation of a motor vehicle,
• Contraception and sex education,
• Actual or potential litigation on behalf of the children.
B. Daily or Everyday Decisions
Daily or everyday decisions are routine decisions like minor medical treatment, bedtimes, homework,
chores, selection of clothing and normal daily activities.
Daily decisions shall be made by the parent having actual physical custody at the time of the decision. The
parents shall cooperate in establishing mutually agreeable policies regarding such decisions in order that routine
decisions remain as consistent as possible.
C. Emergency Decisions
Emergency decisions are decisions of an urgent nature. They affect the health and safety of the children
and have to be made before it is possible to contact the other parent.
The parent who is with the minor child requiring emergency care may make the emergency decision. The
parent making the emergency decision shall advise the other parent of the nature and extent of the emergency as
soon as possible.
6. Access to Medical, Dental and Educational Records of the Children
Unless otherwise provided in this parenting plan, both parents are entitled to access to records and
information pertaining to the children, including, but not limited to, full and complete medical, dental, and
educational records subject to Part A, Paragraph 19.
Parenting Plan Part A - Custody – Page 2
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
7. Legal Custody
You must check one and only one of the following four boxes.
Mother and Father – Joint Legal Custody
It is in the best interests of the children that Mother and Father have joint legal custody of the children.
Major decisions shall be made by Mother and Father jointly. If Mother and Father disagree on a major decision
they shall resolve their disagreement through the dispute resolution procedure set forth herein.
Mother – Sole Legal Custody to Mother
It is in the best interests of the children that Mother has sole legal custody of the children. Major decisions
affecting the children shall be made by Mother. Mother and Father cannot share joint legal custody because:
(Missouri Law requires a statement of the reasons for a request for no shared decision-making. If you do not
enter a reason on this line, the court MUST grant joint legal custody.)
_________________________________________________________________________________________
_________________________________________________________________________________________
Father – Sole Legal Custody to Father
It is in the best interests of the children that Father has sole legal custody of the children. Major decisions
affecting the children shall be made by Father. Mother and Father cannot share joint legal custody because:
(Missouri Law requires a statement of the reasons for a request for no shared decision-making. If you do not
enter a reason on this line, the court MUST grant joint legal custody.)
_________________________________________________________________________________________
_________________________________________________________________________________________
Third Party – Sole Legal Custody to Third Party
It is in the best interest of the children that _____________________ (hereinafter referred to as “Third
Party”) has sole legal and sole physical custody of the children. Major decisions affecting the children shall be
made by Third Party. Both parents are unfit, unsuitable, or unable to be a custodian of the children or the
welfare of the children requires that neither parent have physical custody. (If this box is checked, the same box
MUST be checked under Part A, Paragraph 10.)
8. Communication between Parents
Communication between the parents concerning the children may be by any of the following methods:
Check each box that is appropriate in your case.
In person
Home telephone
Work telephone
Mobile telephone
Letter via U.S. Postal Service
Email
Fax
Via a designated third person. This third person will be ________________________.
The children shall not be used as messengers.
9. Issues not to be Discussed in the Presence of the Children
Mother and Father shall each refrain from making negative, derogatory or degrading statements about the
other parent in front of the children. Both parents shall exercise their best efforts to foster the respect, love and
affection of the children toward the other parent. Mother and Father shall avoid discussing parenting issues,
financial issues, and other topics related to these proceedings when the children are present.
Mother and Father should prevent other persons from making negative, derogatory or degrading statements
about the other parent in the presence of the children.
Parenting Plan Part A - Custody – Page 3
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
When the Children Will Be with Each Parent
“Joint physical custody” means an order awarding each of the parents significant but not necessarily equal,
periods of time during which a child resides with or is under the care and supervision of each of the parents.
Joint physical custody shall be shared by the parents in such a way as to assure the child of frequent, continuing
and meaningful contact with both parents. §452.375.1(3), RSMo.
10. Physical Custody
You must check one and only one of the following nine boxes.
Joint Physical Custody Using Mother’s Address –It is in the best interest of the children that Mother
and Father have joint physical custody of the children. The address of the children for mailing and educational
purposes is the same as that of Mother.
Joint Physical Custody Using Father’s Address – It is in the best interest of the children that Mother
and Father have joint physical custody of the children. The address of the children for mailing and educational
purposes is the same as that of Father.
Sole Physical Custody to Mother and Visitation to Father – It is in the best interests of the children
that Mother has sole physical custody of the children and that Father have visitation as set forth herein.
Sole Physical Custody to Father and Visitation to Mother –It is in the best interests of the children
that Father has sole physical custody of the children and that Mother have visitation as set forth herein.
Sole Physical Custody to Mother and Supervised Visitation to Father – It is in the best interests of
the children that Mother have sole physical custody of the children and Father have supervised visitation as set
forth herein. Unsupervised visitation would endanger the children’s physical health or impair their emotional
development because: __________________________________________________________________
__________________________________________________________________.
Visitation will be supervised by __________________________________________________________.
Sole Physical Custody to Father and Supervised Visitation to Mother - It is in the best interests of the
children that Father have sole physical custody of the children and Mother have supervised visitation as set
forth herein. Unsupervised visitation would endanger the children’s physical health or impair their emotional
development because: __________________________________________________________________
__________________________________________________________________.
Visitation will be supervised by __________________________________________________________.
Sole Physical Custody to Mother and No Visitation to Father – It is in the best interests of the
children that Mother has sole physical custody of the children and Father has no visitation with the children.
Visitation would endanger the children’s physical health or impair their emotional development. Father shall
not have access to records and information pertaining to the children pursuant to §452.376.1, RSMo.
Sole Physical Custody to Father and No Visitation to Mother - It is in the best interests of the children
that Father has sole physical custody of the children and Mother has no visitation with the children. Visitation
would endanger the children’s physical health or impair their emotional development. Mother shall not have
access to records and information pertaining to the children pursuant to §452.376.1, RSMo.
Physical and Legal Custody to a Third Party – It is in the best interest of the children that
_____________________ (hereinafter referred to as “Third Party”) has sole legal and sole physical custody of
the children. Both parents are unfit, unsuitable, or unable to be a custodian of the children or the welfare of the
children requires that neither parent have physical custody. (If this box is checked, the same box MUST be
checked in Part A, Paragraph 7.)
Parenting Plan Part A - Custody – Page 4
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
11. Residential Schedules
Mother and Father shall have physical custody of the children as they agree. In the event they do not agree,
then Mother and Father shall exchange the children as set forth in the residential schedules.
Each parent shall consider reasonable changes when requested by the other parent or the children. If a
significant change is made, either parent may reduce their agreement to writing. All changes are unenforceable
unless in writing and signed by both parents.
12. Location of Exchanges
If a specific location for an exchange is not stated on the schedule, then the exchange shall occur at the
following location:
You must check one and only one of the following four boxes.
All exchanges shall occur at the children’s school or child care provider.
All exchanges shall occur at the Mother’s Residence.
All exchanges shall occur at the Father’s Residence.
All exchanges shall occur at _______________________________________________________________.
13. Transportation
The parent who has the children takes the children to the exchange location. Each party will pay the
expenses associated with his or her own transportation to and from the exchange location unless otherwise
indicated in this parenting plan.
14. Notification of Change from Residential Schedule
In the event either parent cannot exercise the scheduled time with the children, he or she should tell the
other parent as soon as possible, but not later than 24 hours before the start of the scheduled time with the
children. If a parent anticipates that he or she may have to cancel at the last minute, he or she should advise the
other parent of the possible last minute conflict. If a parent fails to notify the other as set forth above, he or she
shall be responsible for the reasonable costs incurred by the other parent.
15. Telephone Contact with Children
Each parent may contact the children in a reasonable manner when the children are with the other parent.
Neither parent shall contact the children at the other parent’s residence later than ____________. (If this line
is left blank, there are no restrictions as to time.)
Each parent shall provide the other parent with the telephone number at which the children may be
contacted. Neither parent shall configure their telephone system in such a manner as to “block” or prevent the
other parent from calling.
When a parent travels with the children, he or she must notify the other parent of the children’s destination.
He or she must also provide a telephone number where the children can be reached.
16. Children’s Activities
Both parents must attempt to accommodate the social and academic commitments of the children during
the time the children are with them. Each parent should attempt to refrain from scheduling activities that occur
primarily when the children are with the other parent. If an activity will affect the other parent’s time with the
children, the parent scheduling the activity should obtain the affected parent’s permission before committing the
children to the activity.
17. Dispute Resolution Procedure
This is the manner in which Mother and Father will resolve disagreements concerning the children. This
includes disagreements on the meaning or interpretation of any provision of this plan. Mother and Father shall
present their disagreements to a mediator chosen by them for non-binding mediation. In the event that the
parents cannot resolve the dispute by mediation, they may submit the issue to the Court through appropriate
proceedings.
Additional dispute resolution procedures are as follows:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Parenting Plan Part A - Custody – Page 5
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Other Provisions Concerning the Children
18. Relocation
§452.377, RSMo states:
“Absent exigent circumstances as determined by a court with jurisdiction, you as a party to this action are
ordered to notify, in writing by certified mail, return receipt requested, and at least sixty days prior to the
proposed relocation, each party to this action of any proposed relocation of the principal residence of the child,
including the following information:
(1) The intended new residence, including the specific address and mailing address, if known, and if
not known, the city;
(2) The home telephone number of the new residence, if known;
(3) The date of the intended move or proposed relocation;
(4) A brief statement of the specific reasons for the proposed relocation of the child; and
(5) A proposal for a revised schedule of custody or visitation with the child.
Your obligation to provide this information to each party continues as long as you or any other party
by virtue of this order is entitled to custody of a child covered by this order. Your failure to obey the order
of this court regarding the proposed relocation may result in further litigation to enforce such order,
including contempt of court. In addition, your failure to notify a party of a relocation of the child may be
considered in a proceeding to modify custody or visitation with the child. Reasonable costs and attorney
fees may be assessed against you if you fail to give the required notice.”
The residence of the child may be relocated sixty (60) days after providing notice unless a parent files
a motion seeking an order to prevent the relocation within thirty (30) days after receipt of notice. Such
motion shall be accompanied by an affidavit setting forth the specific factual bases supporting a prohibition
of the relocation.
19. Domestic Violence between the Parents
You must check one and only one of the following five boxes.
There has been no domestic violence between the parents.
There has been domestic violence by Mother against Father. Any educational records of the children shall
not include the address of Father or the children.
There has been domestic violence by Father against Mother. Any educational records of the children shall
not include the address of Mother or the children.
There has been domestic violence by Mother against Father; however, the educational records of the
children may include the address of Father or the children.
There has been domestic violence by Father against Mother; however, the educational records of the
children may include the address of Mother or the children.
20. Pattern of Domestic Violence between the Parents
You must check one and only one of the following three boxes.
There has been no pattern of domestic violence by either Mother or Father.
There has been a pattern of domestic violence by Mother against Father. This parenting plan best protects
the children and Father from any further violence.
There has been a pattern of domestic violence by Father against Mother. This parenting plan best protects
the children and Mother from any further violence.
21. Other Custody Provisions
_________________________________________________________________________________________
____________________________
Mother
____________________________
Father
____________________________
Attorney for Mother
____________________________
Attorney For Father
____________________________
Guardian ad Litem
Parenting Plan Part A - Custody – Page 6
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Residential Schedules
1. Weekend and Weekday Schedule
Each exchange should be written on the Weekend and Weekday Exchange Schedule. A sample entry for
one of the exchanges may be as follows: “5:30 p.m. Father receives children”. This means that at 5:30 p.m.,
Father will begin a period of time during which the children will be with him.
The last person to receive custody on the Weekend and Weekday Schedule must be different than the first
person to receive custody on the schedule because after each two week period, the cycle repeats itself. There is
always an even number of exchanges for a two week period.
A sample two week exchange schedule is located on Page 5 of these Residential
Schedules.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2. Vacation Schedule
You must select one and only one of the following two options.
No specific weeks will be set aside for our vacations.
Each parent may designate ______ week(s) each year during which they will have exclusive physical
custody of the children and the regular or special exchange schedules do not apply. Father shall have first
choice of weeks in odd-numbered years. Mother will have first choice of weeks in even-numbered years.
The parent with the first choice of weeks must designate the vacation weeks by March 31 of each year.
During this period, the holiday schedule still applies. Neither parent can select a week which would deny
the other parent of a holiday to which they are entitled.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3. Holidays
A different schedule can apply on holidays. The times each parent will have with the children during the
holidays are set forth on the Holiday Exchange Schedule on page 3 of these Residential Schedules.
Include the name of the parent that will have the holiday and how the holiday will be structured. For
example, Memorial Day is always on a Monday. Should the Memorial Day holiday begin at 6:00 p.m. on
Sunday before Memorial Day? Alternatively, should it include the entire weekend? If the entire weekend is
included, then it is possible that one parent may not have a weekend with the children for several weeks.
Holidays and vacations do not alter the “Week One” or “Week Two” designation, but they do apply ahead
of the regular schedule. If the holiday schedule conflicts with any other schedule, the holiday schedule takes
precedence.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Parenting Plan Part A – Residential Schedules – Page 1
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Weekday and Weekend Exchange Schedule
Enter the parent who is receiving custody and the specified time for each exchange.
See page 5 of these Residential Schedules for a sample schedule.
DAY OF WEEK
EXCHANGES FOR DAY
Weekday/Weekend Schedules
Sunday
Monday
WEEK ONE
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
WEEK TWO
Tuesday
Wednesday
Thursday
Friday
Saturday
Parenting Plan Part A – Residential Schedules – Page 2
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Holiday Exchange Schedule
Holiday
Even
Numbered
Years
Odd
Numbered
Years
FATHER or
MOTHER
FATHER or
MOTHER
Physical Custody
From
To
Time
Time
New Year’s Eve
New Year’s Day
King Day
President’s Day
Memorial Day
Independence Day
Labor Day
Thanksgiving
Christmas Eve
Christmas Day
Easter
Other Holidays
(specify)
FATHER is the "Parent Paying Support"
Special Occasions
(specify)
Halloween
Mother’s Day
Father’s Day
Mother’s Birthday
Father’s Birthday
Child’s Birthday
Parenting Plan Part A – Residential Schedules – Page 3
Form CAFC501-01/01/2011
Holiday Schedules
This form is available for free at www.selfrepresent.mo.gov
DETERMINATION OF WEEK ONE AND WEEK TWO
Determination of “Week One” or “Week Two” on the Weekday and Weekend Exchange Schedule
For purposes of this Parenting Plan, WEEK ONE is defined as a week that has Sunday on one of the
following dates:
January
February
March
April
May
June
July
August
September
October
November
December
1
1
1
1
7
4
2
1
1
8
5
3
2
2
2
9
8
5
3
2
2
9
6
4
3
3
3
10
9
6
4
3
10
10
7
5
4
4
4
11
10
7
5
4
11
11
8
6
5
12
12
12
11
8
6
5
12
12
9
7
6
13
13
13
12
9
7
13
13
13
10
8
7
14
14
14
13
10
8
14
14
14
11
9
15
15
15
15
21
18
16
15
15
22
19
17
16
16
16
23
22
19
17
16
16
23
20
18
17
17
17
24
23
20
18
17
24
24
21
19
18
18
18
25
24
21
19
18
25
25
22
20
19
26
26
26
25
22
20
19
26
26
23
21
20
27
27
27
26
23
21
27
27
27
24
22
21
28
28
28
27
24
22
28
28
28
25
23
29
29
29
29
30
31
30
31
30
29
29
31
30
30
31
31
For purposes of this Parenting Plan, WEEK TWO is defined as a week that has Sunday on one of the
following dates:
January
February
March
April
May
June
July
August
September
October
November
December
8
5
5
2
1
1
1
6
3
1
1
1
9
6
6
3
2
2
9
7
4
2
2
2
10
7
7
4
3
3
10
8
5
3
3
10
11
8
8
5
4
11
11
9
6
4
4
11
12
9
9
6
5
12
12
10
7
5
12
12
13
10
10
7
6
13
13
11
8
6
13
13
14
11
11
8
14
14
14
12
9
7
14
14
22
19
19
16
15
15
15
20
17
15
15
15
23
20
20
17
16
16
23
21
18
16
16
16
24
21
21
18
17
17
24
22
19
17
17
24
25
22
22
19
18
25
25
23
20
18
18
25
26
23
23
20
19
26
26
24
21
19
26
26
27
24
24
21
20
27
27
25
22
20
27
27
Parenting Plan Part A – Residential Schedules – Page 4
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
28
25
25
22
28
28
28
26
23
21
28
28
30
29
29
29
31
30
30
29
29
29
30
30
30
31
31
Weekday and Weekend Exchange Schedule
Enter the parent who is receiving custody and the specified time for each exchange.
See page 5 of these Residential Schedules for a sample schedule.
DAY OF WEEK
Since the parties do not
specify an exchange location,
the exchange would occur at
the default location in
Paragraph 12 in Part A of the
Parenting Plan.
EXCHANGES FOR DAY
Sunday
Monday
5:30 p.m. Dad receives children
8:30 p.m. Mom receives children at Mom’s house
WEEK ONE
Tuesday
This entry contains a
mistake. It is unclear
whether it refers to 5:30
a.m. or 5:30 p.m.
Wednesday
Thursday
Friday
5:30 Dad receives children at Daycare
Saturday
Sunday
6:00 p.m. Mom receives children at her house
This entry is also a mistake.
Mom already has the
children with her so she can’t
receive the children. There
should always be an even
number of exchanges for
any two week period.
Monday
WEEK TWO
Tuesday
8:30 p.m. Mom receives children
Wednesday
Thursday
Friday
Saturday
5:30 p.m. Dad receives children at Mom’s house
8:30 p.m. Mom receives children at Mom’s house
Since Dad is the first parent to
receive the children on this schedule,
Mom must be the last parent to
receive the children. Mom has the
children at the start of this schedule.
Parenting Plan Part A – Residential Schedules – Page 5
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
EXHIBIT NO. __________
IN THE CIRCUIT COURT OF _____________________, MISSOURI
(County where court is located)
_________________
(First)
_____________
(Middle)
____________________
(Last)
If this parenting plan is filed after
the case has been filed, you
MUST enter the Case Number.
_________
(Jr./Sr./III)
Petitioner/Plaintiff,
Case No. ____________
-andDivision No. ____________
_________________
(First)
_____________
(Middle)
____________________
(Last)
_________
(Jr./Sr./III)
Respondent/Defendant.
PARENTING PLAN
Part B – Support of the Children
1. Identification of Parties
Check one and only one of the following two boxes.
Mother is the Petitioner/Plaintiff. Father is the Respondent/Defendant.
Father is the Petitioner/Plaintiff. Mother is the Respondent/Defendant.
2. Plan Author(s)
Check all applicable boxes.
Court
Mother
Father
Guardian ad Litem
_________________________
3. Names and Ages of Children
Enter the total number of children to whom this parenting plan is applicable: ___________.
The names and ages of the children (hereinafter referred to simply as “the children”) are as follows:
Full Name of Child
Child’s Age
Parenting Plan Part B - Support – Page 1
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Child Support Calculations
Child Support
Child support is an amount of money paid by one parent to the other parent for the support of the children.
In addition to a regular monthly child support payment, other expenses of the children may be divided between
the parents as child support. Part B of the Parenting Plan contains the calculation of child support and the
allocation of the children’s expenses.
Form 14
Form 14 is a form used to calculate a presumed amount of child support. Form 14 is part of this parenting
plan and is found on Part B, Page 8. The court will usually follow Form 14, however, if the court finds that the
child support calculated pursuant to Form 14 is unjust or inappropriate, it will set child support at a different
amount.
Parents must also determine the allocation and amount of other expenses of the children such as medical
and dental insurance, uncovered medical and dental expenses, day care, and other extraordinary expenses.
These expenses constitute part of the child support obligations of each parent. These other expenses may be
included in the Form 14 calculation, or they may be paid independently of the child support payment.
Parents may agree on an amount of child support and the allocation of expenses. The court does not have
to accept this agreement and can set different support amounts. Even if the parents have agreed on an amount
of child support, THEY MUST STILL CALCULATE A FORM 14 FOR THE COURT. As they work through
this parenting plan, they will also be entering the information that is required for Form 14.
Missouri law further provides that “An award of joint physical custody does not preclude an award of child
support pursuant to Section 452.340 and applicable supreme court rules in determining an amount reasonable or
necessary for the support of the child.” §452.375.12, RSMo. Child support may be appropriate even if both
parties have custody of the children an equal amount of time.
4. Party to Pay Child Support
One party must be called the “parent paying support” and one person must be called the “parent receiving
support”. This is true even if no child support is going to be paid.
You must check one and only one of the following four boxes.
Mother will pay regular monthly child support to Father.
Mother is referred to as “person paying support” and Father is referred to as “person receiving support”.
Father will pay regular monthly child support to Mother.
Father is referred to as “person paying support” and Mother is referred to as “person receiving support”.
No regular monthly child support will be paid by either parent.
Mother will be referred to as “person paying support” and Father will be referred to as “person
receiving support” for the purpose of the Form 14 child support calculation only.
No regular monthly child support will be paid by either parent.
Father will be referred to as “person paying support” and Mother will be referred to as “person
receiving support” for the purpose of the Form 14 child support calculation only.
Parenting Plan Part B - Support – Page 2
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Medical and Dental Insurance for the Children
Cost of Medical or Dental Insurance for the Children
The cost of medical or dental insurance for the children is the monthly amount of any premium paid. If the
parent’s employer deducts the amount of premium from his or her pay, then the cost of medical or dental
insurance includes the amount of the premium paid. It does not include the cost of medical or dental insurance
for the parent, the parent’s spouse, or other children that are not covered by this parenting plan. The cost of
medical or dental insurance for the children is included on Line 6c of Form 14.
Form 14 states: “If the amount of the actual health insurance costs for the children who are the subject of
this proceeding is not available or cannot be verified, the amount of the health insurance costs attributable to the
children who are the subject of this proceeding shall be calculated by dividing the total monthly costs for the
policy of health insurance by the total number of persons for whom the costs are paid or to be paid and then
multiplying the resulting figure by the number of children insured under the policy who are the subject of this
proceeding.”
5. Parent Responsible for Medical Insurance
Form 14
You must check one and only one of the following three boxes.
Neither party is required to maintain medical insurance for the benefit of the children. A health benefit
plan is not available at reasonable cost through either parent’s employer or union. No support rights have been
assigned to the state of Missouri and the Family Support Division is not providing support enforcement services
to either party.
Father shall maintain and pay the cost of medical insurance for the benefit of the children.
Mother shall maintain and pay the cost of medical insurance for the benefit of the children.
6. Parent Responsible for Dental Insurance
You must check one and only one of the following three boxes.
Neither party is required to maintain dental insurance for the benefit of the children. A health benefit plan
is not available at reasonable cost through either parent’s employer or union. No support rights have been
assigned to the state of Missouri and the Family Support Division is not providing support enforcement services
to either party.
Father shall maintain and pay the cost of dental insurance for the benefit of the children.
Mother shall maintain and pay the cost of dental insurance for the benefit of the children.
7. Medical and Dental Insurance for the Children
The total cost of medical and dental insurance paid by Father for the children is ___________ per month.
The total cost of medical and dental insurance paid by Mother for the children is ___________ per month.
You must enter an amount on both lines, even if you enter “0”. These amounts should also be entered on line
6c of Form 14.
In the event either parent is required to maintain medical or dental insurance, the parent providing the
health benefit plan shall provide to the other parent an insurance identification card.
If support rights have been assigned to the state of Missouri or the Family Support Division is providing
support enforcement services to either party, the person paying support shall notify the Family Support Division
regarding the availability of medical insurance coverage through an employer or a group plan, provide the name
of the insurance provider when coverage is available, and inform the division of any change in access to such
insurance coverage.
Parenting Plan Part B - Support – Page 3
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Health Expenses Not Covered by Insurance
8. Medical, Dental, Vision, or Psychological Expenses not Covered by Insurance
You must check one and only one of the following four boxes.
The person receiving support will pay all reasonable and necessary medical and dental expenses of the
children not covered by insurance and the person paying support will reimburse the person receiving support for
_______ percent of all such expenses that are actually paid by the person receiving support and are in excess of
$250 per year per child. This does not include the uninsured extraordinary costs set forth in paragraph 9 below.
No reimbursement of uncovered medical and dental expenses of the children will be allowed unless the person
receiving support submits proof of such expenses to the person paying support in writing within 120 days of the
date said expenses were incurred. Except for good cause, no legal proceedings seeking reimbursement will be
allowed unless instituted within 360 days of the date said expenses were incurred.
Medical and dental expenses are defined by §213(d)(1)(A) of the Internal Revenue Code.
(§454.633.3, RSMo provides that if you have checked this first box in Paragraph 8 and you have not
provided a percentage, then each parent will be responsible for one-half of all reasonable and necessary
medical or dental expenses of the children not covered by insurance except as set forth in Paragraph 9 below.)
The person paying support does not have the financial resources to contribute to the payment of medical or
dental expenses of the children not covered by insurance. The person receiving support will be responsible for
all reasonable and necessary medical or dental expenses of the children not covered by insurance. This does not
apply to the medical costs listed in Paragraph 9 below. §454.603.5(2), RSMo.
All reasonable and necessary medical or dental expenses of the children are covered by insurance.
§454.603.5(1), RSMo.
The person receiving support has not substantially complied with the terms of the health benefit coverage.
The person receiving support will be responsible for all reasonable and necessary medical or dental expenses of
the children not covered by insurance. This does not apply to the medical costs listed in Paragraph 9 below.
§454.603.5(3), RSMo.
9. Payment of Uninsured Extraordinary Medical Costs
Paid by Father
Form 14
Uncovered Extraordinary Medical Costs to be Paid by
Amount of Expense
Father INCLUDED on Form 14
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
The total cost of these uncovered extraordinary medical costs of the children is $___________ per
month. This amount HAS been included in the child support calculation pursuant to Form 14. (You must
include this amount on Form 14 - Line 6d)
Uncovered Extraordinary Medical Costs to be Paid by
Amount of Expense
Mother INCLUDED on Form 14
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
The total cost of these uncovered extraordinary medical costs of the children is $___________ per
month. This amount HAS been included in the child support calculation pursuant to Form 14. (You must
include this amount on Form 14 - Line 6d)
Paid by Mother
Extraordinary medical costs are predictable and recurring, such as expenses for dental treatment,
orthodontic treatment, asthma treatment and physical therapy. These expenses MAY be included in the Form
14 calculation. (If no extraordinary medical costs are to be included on Form 14, you may leave this
information blank.)
Parenting Plan Part B - Support – Page 4
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Child Care Expenses
Child care expenses related to employment are expenses incurred by a parent during periods of time while
the parent is working and the children are in his or her physical custody.
10. Work-Related Child Care Costs
Form 14
You must check one and only one of the following five boxes
There are no reasonable work-related child care expenses incurred by the parties.
The reasonable work-related child care costs of the children to be paid by Father are $___________ per
month. This amount has been included in the child support calculation pursuant to Form 14. The reasonable
work-related child care costs of the children to be paid by Mother are $___________ per month. This amount
has also been included in the child support calculation pursuant to Form 14.
(You must include these amounts on Form 14 - Line 6a(1) for the parent receiving support or Line 6b for the
parent paying support.)
Mother will pay all reasonable work-related child care expenses. The cost of reasonable work-related child
care expenses has NOT been included in the child support calculation pursuant to Form 14. Father will
reimburse Mother for _______ percent of all reasonable work-related child care expenses actually paid by
Mother. Mother will not be entitled to reimbursement from Father unless said payments are appropriately
reported to the Internal Revenue Service. No reimbursement of reasonable work-related child care expenses
will be allowed unless Mother submits proof of such expense to Father in writing within 120 days of the date
said expenses were incurred. Except for good cause, no legal proceedings seeking reimbursement will be
allowed unless instituted within 360 days of the date said expenses were incurred.
Father will pay all reasonable work-related child care expenses. The cost of reasonable work-related child
care expenses has NOT been included in the child support calculation pursuant to Form 14. Mother will
reimburse Father for _______ percent of all reasonable work-related child care expenses actually paid by
Father. Father will not be entitled to reimbursement from Mother unless said payments are appropriately
reported to the Internal Revenue Service. No reimbursement of reasonable work-related child care expenses
will be allowed unless Father submits proof of such expense to Mother in writing within 120 days of the date
said expenses were incurred. Except for good cause, no legal proceedings seeking reimbursement will be
allowed unless instituted within 360 days of the date said expenses were incurred.
Each parent will pay his or her own reasonable work-related child care expenses related to his or her
employment. The cost of reasonable work-related child care expenses has NOT been included in the child
support calculation pursuant to Form 14. Neither parent will reimburse the other parent for any portion of the
child care expenses.
11. Child Care Expenses Unrelated to Employment
Incidental child care costs not related to employment are to be paid by the party with physical custody at
the time the child care costs are incurred.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Parenting Plan Part B - Support – Page 5
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Extraordinary Child-Rearing Costs of the Children
Including College Costs
Extraordinary Child-Rearing Costs
Extraordinary child-rearing costs may include, but are not limited to, the following expenses:
• Educational expenses for college or post-secondary education,
• Special, private or parochial elementary and secondary schooling expenses,
• Tutoring sessions,
• Camps,
• Lessons,
• Athletic activities,
• Travel and other activities intended to enhance the athletic, social or cultural development of a child.
12. Educational Expenses for College or Post-Secondary Education
As used herein, educational expenses for college or post-secondary education (also referred to as college
expenses) include tuition, fees, books, dormitory cost for room and board. It does not include room and board
while residing with either parent. This term shall be the actual cost to the child. In the event the child receives
a scholarship or other aid which reduces the tuition, fees, books, or dormitory costs for room and board, then the
educational expenses for college or post-secondary education does not include the amount of such scholarship
or aid. For this purpose, loans to the student shall not be considered ‘scholarship or other aid’.
The maximum educational expenses for college or post-secondary education, as defined herein, shall not
exceed the cost for tuition, fees, books, and dormitory costs for room and board at the University of Missouri at
Columbia, regardless of what institution the child attends.
Responsibility for educational expenses for college or post-secondary education shall not exceed more than
eight semesters at a college or university.
Continued Eligibility for Child Support when Child is in College
§452.340.5, RSMo provides that “[t]o remain eligible for such continued parental support, at the beginning
of each semester the child shall submit to each parent a transcript or similar official document provided by the
institution of vocational or higher education which includes the courses the child is enrolled in and has
completed for each term, the grades and credits received for each such course, and an official document from
the institution listing the courses which the child is enrolled in for the upcoming term and the number of credits
for each such course.”
The child must carry a minimum number of credit hours each semester.
13. Extraordinary Child-Rearing Costs
Extraordinary child-rearing costs incurred by the parents may be included on Form 14, or the parents may
agree to divide these costs on some percentage basis. The extraordinary child-rearing costs are to be paid as set
forth in the next paragraph. (Paragraph 14 of this Parenting Plan)
Parenting Plan Part B - Support – Page 6
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
14. Payment of Extraordinary Child-Rearing Costs of the Children
Extraordinary Child-Rearing Costs Paid by
Amount of Expense
Mother INCLUDED on Form 14
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
The total cost of these extraordinary child-rearing costs of the children is $___________ per month.
This amount HAS been included in the child support calculation pursuant to Form 14. (You must include
this amount on Form 14 - Line 6e)
Paid by Mother
Extraordinary Child-Rearing Costs Paid by
Amount of Expense
Father INCLUDED on Form 14
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
$___________ per month
_______________________________________________________
The total cost of these extraordinary child-rearing costs of the children is $___________ per month.
This amount HAS been included in the child support calculation pursuant to Form 14. (You must include
this amount on Form 14 - Line 6e)
Extraordinary Child-Rearing Costs Paid by
Father NOT INCLUDED on Form 14
_______________________________________________________
_______________________________________________________
_______________________________________________________
Percentage to be Paid by
Mother to Father
_______%
_______%
_______%
Mother will reimburse Father for the percentage amount of each of these extraordinary child-rearing costs
of the children so long as they are actually paid by Father. No reimbursement of extraordinary childrearing costs of the children will be allowed unless Father submits proof of such expense to Mother in
writing within 120 days of the date said expenses were incurred. Except for good cause, no legal
proceedings seeking reimbursement will be allowed unless instituted within 360 days of the date said
expenses were incurred.
Extraordinary Child-Rearing Costs Paid by
Mother NOT INCLUDED on Form 14
_______________________________________________________
_______________________________________________________
_______________________________________________________
Percentage to be Paid by
Father to Mother
_______%
_______%
_______%
Father will reimburse Mother for the percentage amount of each of these extraordinary child-rearing costs
of the children so long as they are actually paid by Mother. No reimbursement of extraordinary childrearing costs of the children will be allowed unless Mother submits proof of such expense to Father in
writing within 120 days of the date said expenses were incurred. Except for good cause, no legal
proceedings seeking reimbursement will be allowed unless instituted within 360 days of the date said
expenses were incurred.
Parenting Plan Part B - Support – Page 7
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Paid by Father
b. Extraordinary Child-Rearing Costs NOT INCLUDED on Form 14
Paid by Mother
Form 14
Paid by Father
a. Extraordinary Child-Rearing Costs INCLUDED on Form 14
FORM NO. 14 CHILD SUPPORT AMOUNT CALCULATION WORKSHEET
FATHER /
MOTHER is the “Parent Paying Support”
Total Number of Children: ________
PARENT
RECEIVING
SUPPORT
PARENT
PAYING
SUPPORT
COMBINED
1. MONTHLY GROSS INCOME
1a. Monthly court-ordered maintenance being received
2. ADJUSTMENTS
2a. Other monthly child support being paid under court or administrative order
2b. Monthly court-ordered maintenance being paid
2c. Monthly support obligation for other children
(1) Number of other children primarily residing in each parent’s custody
(2) Each parent’s support obligation from support schedule using the parent’s
Line 1 monthly gross income
(3) Monthly child support received under court or administrative order for
children included in line 2c(1)
2c. TOTAL adjustment [Line 2c(2) minus Line 2c(3)]
3. ADJUSTED MONTHLY GROSS INCOME (sum of lines 1 and 1a, minus lines 2a, 2b
and 2c)
4. PROPORTIONATE SHARE OF COMBINED ADJUSTED MONTHLY GROSS INCOME
(Each parent's line 3 income divided by combined line 3 income)
5. BASIC CHILD SUPPORT AMOUNT
(From support chart using combined line 3 income)
Calculated Amount
Calculated Amount
Calculated Amount
Calculated Amount
Calculated Amount
Calculated Amount
0.0%
Calculated Amount
Calculated Amount
0.0%
Calculated Amount
Calculated Amount
6. ADDITIONAL CHILD-REARING COSTS OF PARENTS
6a. Child Care Costs of Parent Receiving Support
(1) Reasonable work-related child care costs of parent receiving support
(2) Child Care Tax Credit (See Form 14 Directions)
6a. TOTAL adjusted Child Care Costs [Line 6a(1) minus Line 6a(2)]
Paragraph 10
Calculated Amount
Calculated Amount
6b. Reasonable work-related child care costs of the parent paying support
Paragraph 10
6c. Health insurance costs for children who are the subjects of this proceeding
Paragraph 5
6d. Uninsured agreed-upon or court-ordered extraordinary medical costs
Paragraph 9
6e. Other agreed-upon or court-ordered extraordinary child-rearing costs
Paragraph 14a
7. TOTAL ADDITIONAL CHILD-REARING COSTS (Enter sum of lines 6a, 6b, 6c, 6d
and 6e)
Calculated Amount
Calculated Amount
8. TOTAL COMBINED CHILD SUPPORT COSTS (Sum of line 5 and line 7)
9. EACH PARENT'S SUPPORT OBLIGATION (Multiply line 8 by each parent's line 4)
Calculated Amount
Calculated Amount
Calculated Amount
Calculated Amount
10. CREDIT FOR ADDITIONAL CHILD-REARING COSTS (Line 7 of parent paying
support)
Calculated Amount
11. ADJUSTMENT FOR A PORTION OF AMOUNTS EXPENDED DURING PERIODS OF
OVERNIGHT VISITATION OR CUSTODY. (See Form 14 Directions)
(Multiply line 5 by
%)
Calculated Amount
12. PRESUMED CHILD SUPPORT AMOUNT (Line 9 minus lines 10 and 11)
Calculated Amount
Income and Expense Statement
Parenting Plan Part B - Support – Page 8
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
Amount of Child Support
15. Presumed Monthly Amount of Child Support
The amounts in Paragraph 15 are
automatically calculated for you
as you complete Form 14.
Complete all applicable amounts. The court-ordered support amount is set forth in Part B, Paragraph 17.
The presumed child support amount calculated pursuant to Form 14 for six children is: ____________.
The presumed child support amount calculated pursuant to Form 14 for five children is: ____________.
The presumed child support amount calculated pursuant to Form 14 for four children is: ____________.
The presumed child support amount calculated pursuant to Form 14 for three children is: ____________.
The presumed child support amount calculated pursuant to Form 14 for two children is: ____________.
The presumed child support amount calculated pursuant to Form 14 for one child is:
____________.
16. Should the court order the child support pursuant to Missouri Child Support Guidelines?
You must check one and only one of the following two boxes.
Yes. The court-ordered child support is the same as the presumed children support amount. The presumed
child support amount as calculated herein is not rebutted as being unjust and inappropriate.
No. The court-ordered child support is different than the presumed children support amount. After
consideration of all relevant factors pursuant to §452.340.8, RSMo and Form 14, the child support as calculated
herein is rebutted as being unjust and inappropriate.
NOTE: Court-ordered child support will be set at the time of the court proceeding. The court is not bound by
the suggestions of the parties and may set an amount greater or lesser than the suggested amounts of courtordered child support set forth in this parenting plan. If the court approves and adopts this plan, then the
support provisions herein will become the order of the court.
17. Court-Ordered Child Support
This is the amount of child support that actually will be paid by the parent paying support.
Form 14
You must check all applicable boxes.
Six or More Children - The person paying support is to pay to the person receiving support
____________ per month when the person receiving support is entitled to support for six or more children
covered by this parenting plan.
Five Children - The person paying support is to pay to the person receiving support ____________ per
month when the person receiving support is entitled to support for five children covered by this parenting plan.
Four Children – The person paying support is to pay to the person receiving support ____________ per
month when the person receiving support is entitled to support for four children covered by this parenting plan.
Three Children - The person paying support is to pay to the person receiving support ____________ per
month when the person receiving support is entitled to support for three children covered by this parenting plan.
Two Children - The person paying support is to pay to the person receiving support ____________ per
month when the person receiving support is entitled to support for two children covered by this parenting plan.
One Child - The person paying support is to pay to the person receiving support ____________ per month
when the person receiving support is entitled to support for one child covered by this parenting plan.
NOTE: You should check each box that applies. For example, if this parenting plan pertains to three
children, then you should check the boxes for three children, two children and one child. You should also enter
an amount of support for three children, two children, and one child respectively. You must attach a Form 14
for each level. For example, if you have three children, then you must attach one Form 14 for three children,
one Form 14 for two children, and one Form 14 for one child.
If you check one of the boxes above, you must check all the boxes below it. Once again, if you only check
the box for two children and do not check the box for one child, then no support is owed when only one child
remains.
Parenting Plan Part B - Support – Page 9
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
18. Starting Date for Child Support
You must check one and only one of the following two boxes if either party is paying child support in Part B,
Paragraph 17.
The first child support payment is due on the date of the entry of the judgment.
The first child support payment is due on _______________________.
Notification by the Person Receiving Support when Child Support Changes
Missouri law provides that “[u]nless otherwise agreed in writing or expressly provided in the judgment,
provisions for the support of the child are terminated by emancipation of the child. The parent entitled to
receive child support shall have the duty to notify the parent obligated to pay support of the child’s
emancipation and failing to do so, the parent entitled to receive child support shall be liable to the parent
obligated to pay support for child support paid following emancipation of a minor child, plus interest.”
§452.370.4, RSMo.
Income Tax Considerations
19. Income Tax Dependents
The parties shall be entitled to claim the minor children as dependents for income tax purposes as follows:
(Person paying support must be current with all support obligations as of December 31 of the tax year in which
the child is to be claimed. Each parent will sign any appropriate documents to allow the other parent to make
such claims.)
NOTE: The Form 14 calculation assumes that the person receiving support will claim the children as
dependents. If the person paying support is entitled to claim one or more of the children, then the Form 14
guidelines are unjust and inappropriate and the second box in Paragraph 16 should be checked.
If the person claiming the children is not listed below, then the person receiving support shall be entitled to
claim the omitted children as dependents in all years.
Name of Child
In odd numbered tax years,
this parent will claim this
child as a dependent
Parenting Plan Part B - Support – Page 10
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
In even numbered tax years,
this parent will claim this
child as a dependent
Payment of Child Support and Wage Assignments
Wage Assignment
A wage assignment means that the child support is taken directly out of the paycheck of the person paying
support. The amount withheld is sent to the Family Support Payment Center. The Family Support Payment
Center will then forward the support to the person receiving support. Child support withheld pursuant to a wage
assignment cannot be sent directly to the party receiving support. A record will be kept of all payments.
If a wage assignment is not ordered, then the child support may be paid directly to the person receiving
support. The person paying support may also voluntarily send payments to the Family Support Payment Center.
If the child support is not paid to the Family Support Payment Center, it is extremely important that each parent
keep accurate records of the amount of child support paid. This means that the party paying support may not
receive credit for his or her payments if he or she does not have receipts or cancelled checks. Because of this, it
is proper to request a receipt from the parent receiving support.
If the person paying support is currently unemployed or self-employed, the wage assignment may still be
ordered, but it will not take effect until the person paying support begins receiving regular wages.
20. Method of Payment of Child Support
You must check one and only one of the following five boxes if either party is paying child support in Part B,
Paragraph 17.
A wage assignment will not issue because a written agreement has been reached between the parties that
provides for an alternative arrangement. Child support shall be paid directly to the person receiving support.
A wage assignment will not issue because there is good cause not to require immediate income withholding
for the reason that implementation of an immediate wage withholding would not be in the best interest of the
child and the person paying support has made timely payments of all previously ordered support. Child support
shall be paid directly to the person receiving support.
A wage assignment will not issue because a written agreement has been reached between the parties that
provides for an alternative arrangement. Child support shall be paid directly to the Family Support Payment
Center, PO Box 109001, Jefferson City, Missouri, 65110-9001.
A wage assignment will not issue because there is good cause not to require immediate income withholding
for the reason that implementation of an immediate wage withholding would not be in the best interest of the
child and the person paying support has made timely payments of all previously ordered support. Child support
shall be paid directly to the Family Support Payment Center, PO Box 109001, Jefferson City, Missouri, 651109001.
A wage assignment will be prepared by the person receiving support and issued by the Circuit Clerk upon
the effective date of this judgment. Child support is ordered to be paid to the Family Support Payment Center,
PO Box 109001, Jefferson City, Missouri, 65110-9001.
21. Additional Provisions Pertaining to Support of the Children:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
____________________________
Mother
____________________________
Father
____________________________
Attorney for Mother
____________________________
Attorney For Father
____________________________
Guardian ad Litem
Parenting Plan Part B - Support – Page 11
Form CAFC501-01/01/2011
This form is available for free at www.selfrepresent.mo.gov
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Print Income and Expenses
Clear All Forms
Table of Contents
Form CAFC721 – Notice of Hearing
Notice must be sent to every party in this case
In what Missouri county is this case
pending?
In the Circuit Court of
What is the case number in the
pending case?
Case Number
Parties
Information
shown in blue
on this form
does not print.
MISSOURI
1. Petitioner or Plaintiff is:
Division Number
____________________________________________.
(Full Name of Petitioner/Plaintiff)
2. Respondent or Defendant is: ____________________________________________.
(Full Name of Respondent/Defendant)
Information
about the
Hearing
3. Type of matter to be heard: _____________________________________________
4. Date and Time of Hearing: _______________________ at _____________ a.m./p.m.
(Date of Hearing)
(Time of Hearing)
(What, When, Where)
The hearing will be held promptly at the Courthouse in the above County and Division.
Party Giving
Notice
► _________________________________
SIGN HERE
___________________________
PRINT YOUR NAME HERE
__________
BAR NUMBER
______________________________________________________________________
(Street)
_________________________
(City)
__________________
(Telephone Number)
Proof of
Service
__________________
(State)
_______________
(Fax Number)
______________
(Zip)
_____________________________________
(Email Address)
I certify under oath that I have given _____________________ a copy of this Notice of Hearing
pursuant to Missouri Supreme Court Rule 43.01(d) by: (You MUST check at least ONE of the
following four boxes)
Mailing a copy to the other party or his or her attorney on ____________________ (Date)
at the following address:
______________________________________________________________________
(Street)
_________________________
__________________
______________
(City)
(State)
(Zip)
Handing a copy to the other party or his or her attorney on ____________________(Date).
Sending a copy to the other party or his or her attorney by fax to
_______________ (fax number) on ____________________ (Date) at ____________ (Time).
Sending a copy via electronic mail to the other party or his or her attorney at
________________________________ (Email Address) on ____________________ (Date).
Affiant, of lawful age, being duly sworn on his or her oath, states that he or she is the affiant
named herein and that the facts stated in this Notice of Hearing are true according to his or her
best knowledge and belief.
►__________________________________
__________________________________
Affiant – SIGN HERE
Affiant – PRINT YOUR NAME HERE
Subscribed and sworn to on ____________________.
________________________
Notary Public
My Commission Expires: _________________________
Notice of Hearing - Page 1 of 1
Form CAFC721-07/01/2012
This form is available for free at www.selfrepresent.mo.gov